Clinical Social Worker - MSW - Weekends

Carilion Clinic•Roanoke, VA

2d•$63,378 - $95,077•Onsite

About The Position

The Social Worker, Masters provides psychosocial assessment, care planning, and discharge support, collaborates with the care team and community resources, and ensures high-quality patient-centered services. The clinical social worker provides psychosocial assessments, interviews, and/or treatments and discharge planning to patients and families to assist them in coping with hospitalization, illness, diagnosis, and/or life situation. The social worker works collaboratively with other members of the health care team, community resources, regulatory agencies and third party payers in order to facilitate the transition of the patient through the organization while maintaining the highest quality of services possible. The social worker will adhere to the National Association of Social Work Code of Ethics. The clinical social worker utilizes critical thinking skills, advanced problem solving, therapeutic interventions and advanced care planning in the day to day functions.

Requirements

Master’s degree from an accredited School of Social Work required.
Minimum of 2 years of social work experience in a healthcare setting preferred.
Strong interpersonal, communication, and teamwork skills.
Demonstrated knowledge of social work theory and practice, including clinical assessment, crisis intervention, and problem-solving.
Ability to work effectively as part of a multidisciplinary team.
Strong analytical skills, cultural competence, and professional integrity.
Must successfully complete orientation and competency validation requirements.

Responsibilities

Conducts a complete psychosocial assessment of the patient and family when services are initiated. For hospice, contact is made within 5 days of start of care.
Formulates, develops, and implements a comprehensive treatment plan and/or plan of care utilizing appropriate social work interventions that may include short-term individual counseling, community resource planning, crisis intervention, and patient/caregiver education.
Reviews and updates the interdisciplinary team (IDT) plan of care as often as necessary (at least every 14 days for Hospice) and contributes to the medical plan of treatment at recertification.
Achieves documentation standards for quality, timeliness, and confidentiality of medical records in accordance with organizational and departmental defined policies and procedures. Adheres to established productivity measures or departmental expectations. Ensures orders are in place for services, as necessary. Reports changes in emotional, social, or financial condition of the patient or family to the provider.
Maintains an extensive knowledge of benefit plans, regulatory guidelines and resources; acts as a consultant to hospice program staff as indicated; participates in the quality improvement reviews and evaluation of social work services.
Remains current with social work and health care developments; seeks opportunities to enhance job related knowledge.
Delivers or supervises the delivery of social work services to the patient or the patient's family. Provides supervision, teaching and training for students, staff and other disciplines as indicated.
Conducts abuse/neglect screening, suicide intervention, behavioral contracting, financial counseling, discharge planning, and/or guardianship processes as indicated.
Leads advance care planning (ACP) and end of life discussions, assists with ACP document completion where needed. Provides therapeutic interventions to achieve goals of care; establishes and maintains appropriate boundaries with patients/families.
Performs other duties as assigned.
Is an integral part of the care team, contributing professional expertise to support the holistic health of the patient and support for family and/or other caregivers. In collaboration with the health care team the medical social worker assists patients and families with personal and environmental difficulties which predispose illness or interfere with obtaining maximum benefits from medical care. Services include advising family and caregivers, providing education and support, and making referrals for other services as needed or requested.
Provides psychosocial assessments of patients and families to identify emotional, social and environmental strengths and problems related to their preventative health management, diagnosis, illness, treatment, and/or life situation. Utilize assessment and social work experience to plan and coordinate patient care.
Formulate, develop, and implement a comprehensive treatment plan utilizing appropriate social work interventions. Coordinate the plan with the care team and make recommendations for further treatment for the patient to achieve his/her optimal level of healthy lifestyle, behaviors and functioning. Evaluate the process at appropriate intervals and modify or change the plan as necessary. Monitors utilization of healthcare resources such as ED, urgent care, admissions or frequent office visits. Collaborates with team to address unnecessary utilization and plan for appropriate support to modify process behaviors. Monitor, evaluate, and record client progress according to measurable goals described in treatment and care plan.
Arranges, secures, and coordinates assistance with unmet patient/family needs, to include social service, financial, and insurance applications and follow up, medications, DME, and transportation to/from clinic appointments. Plan of care promotes compliance as well as considers appropriate utilization of resources. Advocates on behalf of the patient. Advocates for patients to assist in crises situations.
Collaborates with other professionals to evaluate patients' medical or physical condition and to assess patient needs.
Collaborates with community agencies and resources to develop comprehensive knowledge base of available resources for patients and families. Networks with community resources to build strong working relationships. Maintains an extensive knowledge of benefit plans, regulatory guidelines and resources and serves as a resource to maximize utilization and cost effectiveness.
Refer patient or family to community resources to provide access to services such as financial assistance, legal aid, or housing. Refer to DSS with suspected abuse or neglect of child or adult.
Participates in care team pre- and post-visit case reviews and related meetings. Collaborates with the health care team and/or care coordinator verbally or via chart entries related to the patient's progress toward reaching expected outcomes or about barriers to the plan. Modify treatment plans to comply with changes in client's status.
Provides education and self-management strategies to patients and families around issues related to adaptation of the patient's health and addressing any contributing barriers to achieving goals.
Meets documentation standards for quality, timeliness and confidentiality of medical records in accordance with organizational and departmental defined policies and procedures. Maintains records and statistics in accordance with department and medical center policies. Adheres to established productivity measure.
Provides education to patients and families around issues related to adaptation of the patient's illness and /or life situations.
Formulating a comprehensive care transition plan coordinated with the interdisciplinary/ transdisciplinary team.
Identifying emotional, social, environmental strengths and problems related to their diagnosis, illness, treatment, and/or life situation.
Plans of care will be compliant and consider appropriate utilization of resources.
Assessments will be re-evaluated at appropriate intervals for modification needs.
Plans will involve direct coordination with patient, or designated decision maker, and be conducted face to face whenever possible.
Staff will maintain an extensive knowledge of benefit plans, regulatory guidelines and resources to maximize utilization and cost effectiveness.
Documentation will be professional, full, complete, and absent of errors.
Documentation will be ongoing and timely reflecting updates on progress toward reaching expected outcomes or barriers to progression.
All work will meet federally regulated timelines (i.e. for assessments and discharge plans).
Facilitates and interdisciplinary approach to patient care.
Actively participates in interdisciplinary meetings sharing meaningful and profession based assessments regarding progression of care.
Provides feedback to the care team via verbal, electronic, and through ongoing documentation.
Daily communication with Case Manager and Utilization Review: includes case reviews, morning touchpoints, and ongoing throughout the work day.
Maintains effective communication with all disciplines to promote timely and appropriate transitions of care.
Advocates for the patient throughout the episode of care.
Provides therapeutic interventions aimed at adaptation throughout the continuum of care.
Identifies and support the range of emotions and coping styles of patients and families.
Participates in system and departmental performance improvement initiatives
Adheres to productivity measures.
Successful utilization of predictive analytics software to meet organizational/departmental initiatives, goals.
Collects and analyzes relevant patient care and fiscal data.
Monitors length of stay for level of care appropriateness and need for continued stay.
Identification and capture of avoidable delays.
Escalation of delays and opportunities internal to system and external
Complies with all departmental policies, procedures, and standards of practice.
Care Transitions for the discipline include: Inpatient Rehab Facility, Long-term Care, Assisted Living Facility, Skilled Nursing Facility, Substance Abuse triggers: interventions and referrals, Shelters/Homeless, Reintegration into the community with Medicaid personal care and waivers, Hemodialysis, Care coordination with outpatient based mental health support, Adoption, Community based referrals and resource linkage.
Coordinates financial counseling and referrals timely.
Virginia UAI and other state screenings/ required documents for transitions of care within the scope of this role.
Facilitates abuse/neglect/intimate partner violence consults.
Coordination of guardianship/judicial authorizations in conjunction with Carilion Legal Department.
Completes/Educates on advance directives/living wills.
Collaborates and networks with post-acute providers, community agencies and resources.
Assists with arranging transportation and securing appropriate documentation.
Family Meetings both with/without other members of the care team.
Daily case collaborations with Case Manager and Utilization Review.
Other duties as assigned based on business/ patient care needs.