Inpatient Medical Social Worker

Advocate Health•Skaneateles, NY

17h•$31 - $46

About The Position

The Inpatient Medical Social Worker provides social work and care coordination services to patients and families throughout the hospital stay. The role conducts psychosocial assessments, evaluates needs, develops plans, delivers interventions and follow-up, and supports safe, timely discharge planning and transitions of care. The social worker partners with patients, families, the RN Care Manager, medical staff, and multidisciplinary teams to address care needs, patient choice and satisfaction, barriers to discharge, and continuity of care. The position coordinates access to post-acute placement, palliative and hospice services, medical equipment, home health care, outpatient follow-up, mental health resources, community agencies, and other services. It also performs utilization management activities as required, including payer updates, denial coordination, avoidable-delay management, and delivery of applicable CMS notices. The social worker supports patients and families with community resources, advance directives, end-of-life concerns, bereavement, ethical issues, and social matters such as suspected abuse or neglect and domestic violence. The role documents activity, manages patient progression and length of stay, supports care across the continuum to reduce unnecessary readmissions, and may participate in staff orientation, student education, and legal proceedings. A master’s degree in social work from a CSWE-accredited school is required. State-specific licensure or certification requirements apply; LCSW is preferred where indicated. The role typically requires two years of social work experience in healthcare. The position involves travel, exposure to office and patient-care environments, and required weekend, holiday, and evening coverage according to site requirements. The schedule is three 10-hour shifts per week with rotating weekends and holidays; hours per week are listed as 30.

Requirements

Master’s degree in social work from a Council on Social Work Education (CSWE)-accredited school.
Typically two years of social work experience in healthcare.
Illinois: LSW eligibility; LCSW preferred, issued by the State of Illinois.
Wisconsin: Social Work Certification issued by the State of Wisconsin.
CLT: Master’s in Social Work required; LCSW preferred; applicable state certification preferred.
Georgia: Applicable state certification preferred.
Adherence to the National Association of Social Workers Code of Ethics.
Knowledge of social work principles and methods and ability to apply them in a healthcare setting.
Time management, professional accountability, and documentation skills.
Communication skills and ability to collaborate within a multidisciplinary team.
Ability to act in accordance with the safety principles of an accountable care organization.
Ability to provide care appropriate to the age and developmental needs of patients served.
Ability to travel and work in office and patient-care environments; weekend, holiday, and evening coverage is required according to site requirements.

Nice To Haves

LCSW, where specified as preferred.
Applicable state certification, where specified as preferred.

Responsibilities

Conduct psychosocial assessments, determine patient and family needs, develop appropriate plans, and initiate interventions and follow-up within required timeframes.
Collaborate with patients, families, and the care team on discharge planning and transitions while supporting patient involvement, choice, satisfaction, and organizational care goals.
Provide social work services, including screening, evaluation, intervention, resource coordination, and discharge planning consistent with assessed needs and available resources and payer networks.
Coordinate safe and timely care with the multidisciplinary team, including post-acute placement, palliative and hospice services, medical equipment, home health care, outpatient follow-up, mental health resources, and community resources.
Perform utilization management activities as required, including providing clinical updates to payers or external review organizations, collecting data, coordinating denial activity, supporting UM activity, and managing avoidable delays.
Deliver applicable CMS regulatory notices within established timeframes and site guidelines.
Partner with the RN Care Manager and support personnel to establish and implement safe plans of care; participate in multidisciplinary rounds and work with medical staff and hospital services to resolve discharge barriers and avoid delays.
Maintain knowledge of community resources, legislation, regulations, and healthcare reimbursement issues; educate patients and families as appropriate.
Connect patients to agencies for suspected abuse or neglect, domestic violence, guardianship, and other social matters.
Provide resources and education to support timely discharge and access to post-acute providers, community social services, and continued care.
Support patients and families with bereavement and loss, ethical issues, advance directives, and end-of-life concerns.
Communicate with patients, families, healthcare team members, and community agencies; help resolve continuity-of-care issues such as prior approvals, application requirements, and transfer paperwork.
Document activities according to department and program protocols; manage patient progression to optimize length of stay and ensure appropriate level of care.
Coordinate care across the continuum and within an ACO environment to support outcomes and reduce unnecessary readmissions; remain accountable for site-specific goal achievement.
Participate in orientation of new staff and/or education of social work students.
Educate patients and families about advance directives and assist with execution of documents as appropriate; participate in legal proceedings as needed to secure legal decision-makers.
Maintain professional practice in accordance with applicable accreditation, hospital, system, state, and NASW standards and Code of Ethics.
Complete continuing education required to maintain licensure and develop knowledge in the practice specialty.
Demonstrate age-specific knowledge and skills to assess patient status and provide care appropriate to patients’ developmental and age-related needs.
Operate equipment necessary to perform the job and follow personal protective equipment requirements.