Clinical Social Worker, 40 hours, Days [SARAH Program, Grant Funded]

UMass Memorial Health•Worcester, MA

5d•$58,115 - $104,624

About The Position

Everyone Is a Caregiver At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. Provides assessment of patients/families and their adaptation to patient’s illness. Provides counseling as needed and ensures maximum patient participation in plans for discharge and recovery. Identifies system or discharge problems and develops discharge plans and presents options to patients. Assessment of all potential cases of abuse: child, elderly, disabled and/or domestic violence.

Requirements

Master’s Degree in Social Work.
Current Massachusetts Licensed Clinical Social Worker (LCSW) licensure.
Demonstrated ability in psychosocial assessment, knowledge of community resources, crisis intervention skills, ability in discharge planning, and ability to work with a multidisciplinary team.
Data compilation and analysis skills.
Excellent written and communications skills.
Basic computer skills.

Nice To Haves

One to three years of Social Work experience.
Experience in discharge planning or case management.

Responsibilities

Provides clinical service to patients and their families through individual, family, or group work, such as biopsychosocial assessment, crises intervention, treatment planning and counseling relative to medical conditions.
Identifies clinical resources and make referrals when necessary.
Collaborates with physicians, care coordinators, discharge planners, and other health care professionals to identify barriers to discharge or treatment and help resolve these issues with patients, families, or external sources.
Advocates for patients and families as they negotiate the health care system so that effective care, treatment, and planning may occur.
Documents all information obtained in evaluation, assessment, consultation, referral, and disposition to comply with regulatory requirements, as well as ensuring best possible patient outcome.
Utilizes the language of the current DSM-IV-TR to establish comprehensive diagnostic evaluations and subsequent planning and treatment.
Review referrals and collaborate with inpatient case management clinicians to identify patients appropriate for digital health services in conjunction with the research team. Assists the research team in verifying clinical eligibility and facilitates communication between the inpatient care teams and the SARAH clinicians to ensure all patients’ clinical and social needs are met.
Facilitates the onboarding process of patients to the SARAH program by coordinating with various treatments involved in the patients’ care plans, including the hospital team, rehab therapy providers, command center staff, and geriatricians, to ensure a smooth patient transition.
Lead inter-disciplinary team rounds for patients in the SARAH program to provide coordinated care management, goals of care, and set discharge targets.
Continually evaluate the patient’s readiness for transition to a different level of care or service. Educates the patient, family, and care team regarding resource options, facilitates decision-making, initiates plans, and secures resources for the patient on an ongoing basis.
Procures the necessary services and coordinates the transition with the patient, family, care providers, payers, facilities, agencies, and vendors when patients transition to a different level of care, such as home health or discharge home with or without services.
Coordinates care plans and communication between MIH clinicians and ambulatory team members to ensure continuity and appropriate follow-up for patients.
Identifies and refers eligible patients to special MIH programs (including transitional care services) by performing outreach to inpatient teams, patients and caregivers, and MIH clinicians.