The Medical Social Worker will conduct complete assessments, establish appropriate plans, and initiate interventions within desired timeframes. They will collaborate and negotiate effectively with patients, families, and the healthcare team to achieve patient and organizational goals regarding care needs, choices, and satisfaction during discharge planning and care transitions. The role involves utilizing patient/family strengths in problem-solving, involving them and the team in decision-making from admission throughout the hospital stay. This position provides social work services including psychosocial assessment, screening, needs evaluation, intervention, follow-up, and discharge planning, implementing interventions substantiated by assessment and consistent with available resources and payer networks. The Medical Social Worker participates as part of the multi-disciplinary health care team to develop safe and timely coordination of care, including post-acute placement, palliative/hospice services, medical equipment, home healthcare, outpatient follow-up, mental health resources, and other community resources. They advocate for patient involvement in the plan of care and coordinate interventions with other team members. The role requires staying knowledgeable in healthcare regulations, reimbursement issues, impact on length of stay, and community resources. Additionally, the Medical Social Worker completes UM activities, communicates effectively with the healthcare team, works in partnership with RN Care Managers and unlicensed support personnel, and serves as an active member of the MDR. They maintain up-to-date knowledge of community resources, legislation, and regulations, educating patients and families as appropriate. The position provides resources to patients and families for timely discharge and appropriate links with post-acute care providers, as well as support for bereavement, loss, ethical issues, advanced directives, and end-of-life issues. Collaboration with community agencies and institutions is key for continued care planning and intervention coordination. The Medical Social Worker manages patient care progression to optimize length of stay and ensure appropriateness of assigned Level of Care, and works to decrease unnecessary readmissions and coordinate care within an ACO environment. They are accountable for site-specific goal achievement and participate in the orientation of new staff and/or education of social work students. Education is provided to patients/families regarding Advance Directives, and assistance is given with their execution. Participation in legal proceedings may be necessary. The Medical Social Worker maintains professional standards and responsibilities according to accreditation, hospital, system, state, and NASW Standards and Code of Ethics, and completes all required continuing education to maintain licensure and increase knowledge.
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Job Type
Full-time
Career Level
Mid Level