Clinical Social Worker LCSW - Heart Transplant

Cedars-Sinai Medical Center•Los Angeles, CA

About The Position

The Clinical Social Worker LCSW provides a full range of social work services in collaboration with other medical center staff to address patients’ and families’ psychosocial needs and discharge planning. The role develops, plans, implements, and evaluates social-service interventions for assigned departments and identifies patients with psychosocial needs in inpatient and outpatient settings. In collaboration with the care team, the social worker establishes patient care goals and treatment plans, conducts psychosocial evaluations, identifies barriers to optimal care, and provides crisis intervention and individual and family counseling. The position serves as a clinical resource and mentor to non-licensed staff and consults with physicians and nurse case managers on complex psychosocial needs and advance care planning. It coordinates transitions between inpatient care and outpatient follow-up, participates in interdisciplinary care conferences, evaluates caseload outcomes, adjusts goals with providers, and documents findings in the electronic medical record and case management system. The social worker also connects patients with supportive agencies and community resources, serves as a departmental liaison for advance care planning and complex discharge planning, and participates in continuing education, staff development, and program planning.

Requirements

Master’s degree in Social Work from an accredited college.
Three years of experience in an acute-care hospital setting.
California Licensed Clinical Social Worker (LCSW) license.

Nice To Haves

Two years of clinical social work experience, including palliative or hospice care and discharge planning.
Experience in project management or process improvement.

Responsibilities

Provide clinical social work services to patients and families with psychosocial needs.
Identify patients with psychosocial needs in inpatient and outpatient settings and develop care goals and treatment plans with the care team.
Conduct psychosocial evaluations and develop plans to address problems affecting optimal patient care.
Provide crisis intervention, individual counseling, and family counseling.
Consult with physicians and nurse case managers regarding complex psychosocial needs, advance care planning, treatment, and resources.
Serve as a clinical resource and mentor to non-licensed staff handling complex cases.
Develop, plan, implement, and evaluate social-service interventions and programs for assigned departments.
Perform patient triage within assigned teams and help coordinate care delivery; document pertinent information in the case management system.
Coordinate transitions between inpatient care and continued outpatient follow-up, and vice versa.
Initiate or participate in team care conferences involving patients, families, and care providers.
Review caseloads and progress toward short- and long-term goals; modify goals with providers and the care team based on patient outcomes.
Compile and present patient outcome statistics and reports, and document findings in patients’ electronic medical records.
Follow up on communications with referral sources, including primary care providers, family members, case managers, home health personnel, community social workers, and health plans.
Act as the department’s social-services liaison, particularly for advance care planning, complex discharge planning, and biopsychosocial assessments.
Refer patients to agencies and identify alternatives for specific supportive services, helping patients optimize health-plan benefits.
Arrange community resources such as meals on wheels, transportation, adult day care, and information services, and assist with long-term planning for transitions to institutional settings.
Participate in advance care planning initiatives.
Participate in departmental continuing education, staff development, and program planning.