Plans, organizes and implements social work for patients and families. Works in a team model to address patient care needs. Assesses patients/families in need of psycho-social support throughout the patient’s hospitalization and assists patients who require care coordination or community resources referrals. Advocates for patient self-determination and appropriate level of care. Identifies discharge plan by making arrangements for psycho-social, psychological and practical assistance across the continuum of care. Actively engages the patient and family in the assessment, problem solving and referral process including transfer and discharge plans. Notifies patient/clinical team of potential referrals, documents on the medical record in a timely fashion: psycho-social assessments, identified plan, barriers, changes and progress toward plan completion. Notifies final outcome and patient satisfaction. Interacts with the interdisciplinary team in the development of the treatment/discharge plan addressing the patient’s/family’s psycho-social support. Coordinates family meetings. Assists patients and families in navigating the healthcare system. Performs a variety of functions to address patient’s psycho-social needs with referrals for counseling, community services, protective services, and financial assistance referrals (MA application).
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Job Type
Full-time
Career Level
Entry Level
Number of Employees
5,001-10,000 employees