UHC - Clinical Care Social Worker

WVU Medicine

22h•Onsite

About The Position

This position comprehensively plans for the coordination of care for the WVU Medicine patient population across the continuum. It involves performing psychosocial assessments, crisis intervention, resource management, discharge planning, care facilitation, and referrals to alternate levels of care. The role requires collaborative work with the multidisciplinary care team to achieve desired treatment outcomes. The social worker will intervene with patients who have complex psychosocial needs, assist with eligibility determination for social programs and funding sources, and help patients qualify for community assistance. Additionally, the position may offer crisis intervention to patients and families and collaborate with the patient care team in developing transition/discharge plans.

Requirements

Masters degree in Social Work
Current social worker licensure as required by the state where work is being performed. WV: Licensed Graduate Social Worker (LGSW), Licensed Certified Social Worker (LCSW) or Licensed Independent Social Worker (LICSW) through the West Virginia Board of Social Work MD: Licensed Masters Social Worker (LMSW) or Licensed Certified Social Worker – Clinical (LCSW-C) through the Maryland Board of Social Work

Nice To Haves

One to three years of experience preferred

Responsibilities

Manages all aspects of transition/discharge planning for assigned patients in a timely manner using escalation processes as needed when barriers encountered.
Collaborates with all members of the multidisciplinary team to facilitate the transition/discharge process for designated caseload
Monitors the patient’s progress; intervening as necessary and appropriate, to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective
Maintains extensive knowledge of federal, state, and local assistance programs and community resources that affect patient needs.
Demonstrate appropriate professional practice, maintaining respect for confidentiality and freedom of choice as outlined by the Code of Ethics by the National Association of Social Workers as well as the State Board of Social Workers.
Provides education as needed to staff, physicians, and patients and their families to ensure effective transition planning
Meets directly with the patient and/or family to assess needs and develop an individualized transition/discharge plan in collaboration with the physician team
Provides social work assessment and interventions for complex crisis including but not limited to mental health, substance abuse, adjustment to health status and grief/loss situations.
Communicates with the multidisciplinary team and post-acute providers when applicable, any complex family dynamics that may directly impact patient care and transition/discharge planning
Initiates and facilitates referrals to post-acute services- including but not limited to- Homecare, Durable Medical Equipment, Hospice Care, Long Term Acute Care Facilities, Acute Rehab Facilities, and Skilled Nursing Facilities
Communicates all necessary information regarding transition/discharge plan to the multidisciplinary team, patient and family. Assists other team members to understand and appreciate a patient and/or family’s reaction to a serious illness and/or chronic illness/disease as well as to understand other environmental factors affecting care, treatment and compliance.
Provides timely and comprehensive documentation of interactions with patient and/or families and all transition/discharge planning activities and progress according to regulatory policies and procedures.
Working knowledge of patient’s current medical insurance coverage and limitations and the precertification requirements for Durable Medical Equipment (DME), post-acute placements, infusions, transfers etc.
Assists patient/families with completion of medical power of attorney, health care surrogate, and advanced directives
Utilizes clinical skill and expertise to provide assessment, intervention, and where appropriate, reporting for complex abuse, neglect, Foster Care, adoption, Mental health placement, homelessness, domestic violence, and sexual assault situations.
Collaborate for appropriate resource and financial management which may include but is not limited to-financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination
Communicates with the Care Management Resource Center and/or third party payors to facilitate covered day reimbursement certification for assigned patients and discusses payor criteria and issues on a case by case basis with clinical staff (Ie: peer to Peer) and follows up to resolve problems with payors as needed
May require occasional coverage to outpatient services including but not limited to LVAD assessment/services, Transplant psychosocial assessments and services and for coordination of discharge services with the outpatient organ transplant/LVAD clinic staff.
Uses quality screens in the electronic record to identify potential issues including but not limited to- avoidable delays and readmissions
Educates hospital staff and physicians to payer regulations and managed care principals to prevent denials
Fosters the integration of staff and/or students into the healthcare team
Exhibits professional behavior on a consistent basis
Required on call and weekend/holiday rotations as needed