Clinical Social Worker

South Shore Health•Norwell, MA

1d•Onsite

About The Position

The Clinical Social Worker acts as a patient advocate to SSH & SSMC clients. Works in coordination with the RN Case Manager to coordinate, negotiate, procure services and resources for and manage the transitional care planning of patients to facilitate achievement of quality and cost-effective patient outcomes. Responsible to work with a multi-disciplinary patient care team to optimize care coordination, behavioral and mental health and wellness, monitor patients through admissions, ED visits and collaborate with other stakeholders to transition home/to the community post discharge. This role requires varying degrees of follow-up and follow through, including fostering, executing, and expediting efficient care coordination and assessing the needs of patients and families. Works collaboratively with the interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. Utilizes SMART GOAL formation and clear, precise documentation regarding patient outcomes and interventions.

Requirements

Master's required.
Must be independently licensed.
Demonstrates competency in basic computer and keyboard skills required
Social worker experience required.
LICSW – Independently Licensed Certified Social Worker or LMHC – Must be independently licensed
Excellent communication skills required: ability to work independently and autonomously.
Ability to manage time, set priorities and self-origination will be essential to success of employee.
Ability to work within a multidisciplinary team and in collaboration with the RN Case Manager and supporting staff.

Nice To Haves

EPIC and Outlook preferred.
Knowledge of basic medical terminology preferred.
Recent healthcare experience or related field preferred.
Experience working with pediatric patients and families, elders and their caregivers, and/or various other community populations desirable.

Responsibilities

Respond to and prioritize urgent high-risk cases such as Crisis interventions, Depression Screening referrals, Pedi BH referrals, Adult Protective Service (APS) and/or Child Protective Service (CPS) referrals, Guardianship referrals
Coordinate appropriate community and resource specific referrals (Financial, Educational, Counseling/family support agencies)
Complete and document initial psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission/one business day or within 24 hours of referral
Review work list/census to prioritize patients and identify those that meet criteria for social work interventions as needed; (attending Monday morning CMS Teams Huddle on upcoming patients)
Review patients in settings: ED when necessary, Skilled Nursing Facilities – as needed for staff consult, Coordination with VNA/Home Health or Family support when patient has been discharged home
If discharge plan initiated, verify demographics and insurance information is correct
Coordinate with CMs in various departments to ensure continuity of care and support
Complete and document initial psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission/one business day or within 24 hours of referral
Follow progress of patient from Pre-surgical teaching/planning through 30 day post-procedure episode
SW may be asked to be involved in discharge and or transition planning for CMS Teams patients across their episodic surgical journey
Attend and actively participate in IDRs for assigned units
Report during IDRs: Patient's insurance, Psychosocial barriers, Anticipated Plan of Care, Patient/family concerns, Follow-up items for SW/CM
Identify patients that would benefit from SW intervention or support
Report resource limitations on post-acute care benefits or denials that could impact the discharge planning
Document avoidable delays identified during IDRs
Communicate with care team (Physician, Provider, Nursing Staff, Ancillary) about identified psychosocial issues or barriers that might delay or prevent timely discharge
Update CM counterparts/care team daily or more often if necessary
Collaborate with internal team and external agencies to coordinate care and timely discharge: Facilitate patient care conferences and patient/family meetings, Coordinate with APS/CPS agency personal and assist with meetings, Coordinate with legal system (guardianship/adoption)
Ensure patient/family is updated and involved in the care plan
Escalate to Case Management leadership and/or Physician Advisor (PA)
Escalate all high-risk cases that will require additional attention or resources in order to remove risks and barriers to a timely discharge
Provide when appropriate the following regulatory notifications: Medicare Outpatient Observation Notification (MOON), Important Message from Medicare (IMM), Detailed Notice of Discharge (DND), Hospital-Issued of Non-Coverage (HINN), Advance Beneficiary Notice (ABN)
Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.
Embraces technological advances that allow us to communicate information effectively and efficiently based on role.