Medical Social Worker - Oncology, Inpatient, & Swing Bed Services

University of Vermont Health Network•Malone, NY

2d•Onsite

About The Position

This is a full-time, on-site social work position providing comprehensive medical social work services across the inpatient medicine unit, swing bed program, and outpatient oncology clinic. Delivers patient-centered psychosocial assessment, care planning, case management, and care coordination to support patients and families across the continuum of care. Collaborates with interdisciplinary teams, community partners, and post-acute providers to address complex psychosocial, medical, and discharge needs, promote safe transitions of care, and improve patient outcomes. Provides medical social work services to patients admitted to the inpatient medicine unit by identifying psychosocial needs early in hospitalization and completing timely, comprehensive assessments. Participates in interdisciplinary rounds alongside physicians, nursing, case management, and allied health professionals to support care planning, address barriers to discharge, and facilitate smooth transitions of care. Delivers discharge planning services from admission through discharge, including patient and family education, coordination of post-hospital services, and direct communication with community providers to ensure safe and effective follow-up care. Supports the swing bed program through participation in admissions, completion of psychosocial assessments, and ongoing discharge planning for post-acute patients. Coordinates services to address medical, functional, and psychosocial needs, including involvement in long-stay reviews and interdisciplinary care planning meetings as indicated. Establishes and maintains collaborative relationships with community-based organizations, durable medical equipment providers, home health agencies, and other post-acute partners to ensure continuity of care following discharge. Maintains a regular on-site presence in the outpatient oncology clinic to provide specialized psychosocial support, case management, and care coordination for patients and caregivers affected by cancer. Assesses emotional, practical, financial, and caregiver needs throughout diagnosis, treatment, survivorship, and end-of-life care. Facilitates referrals to oncology-specific programs, palliative care, hospice, support groups, and community resources, and collaborates closely with oncology providers to address distress, support advance care planning, and enhance quality of life for patients and families.

Requirements

Master of Social Work (MSW) degree from an accredited school of social work.
Minimum of one year of experience in a hospital or comparable health care setting preferred.
Current New York State licensure as a Licensed Master Social Worker (LMSW) required, LCSW-preferred.
Demonstrated knowledge of community resources, support services, and oncology‑related programs and networks.
Demonstrated emotional sensitivity, clinical judgment, and interpersonal skills to effectively support patients and family members experiencing serious illness, distress, or crisis.
Ability to collaborate effectively with interprofessional teams, hospital departments, UVM Health Network partners, community agencies, and Cancer Center personnel.
As applicable, the individual has training/competency in attending to the special needs and/or behaviors appropriate to the age of the patients for which care is being provided.

Nice To Haves

LCSW-preferred

Responsibilities

Provides care to adult and geriatric patients
Provides psychosocial and supportive interventions for patients and families identified as needing social work services.
Demonstrates competence in the utilization of individual and family approaches to psychosocial support, and coordinates psychosocial support and services needed by patients and family members throughout the full continuum of care.
Assists patients and families with plan‑of‑care concerns and options, including arranging transportation and lodging, navigating insurance coverage, accessing medication and supply assistance programs, and securing necessary care resources.
Recognizes services in need of development or improvement and formulates plans for implementation in collaboration with interdisciplinary and community partners and evaluates the effectiveness of services and support systems in meeting patient and family needs.
Documents assessments, interventions, referrals, and outcomes consistent with established regulatory, accreditation, and hospital requirements.
Participates regularly in multidisciplinary patient conferences, providing psychosocial input related to follow‑up, referrals, and care planning.
Develops and maintains a system for assessment of psychosocial needs for Cancer Center patients to inform psychosocial treatment planning.
Works as a liaison between the Cancer Center, and including but not limited to, inpatient units (including R5 at CVPH and Miller 5 at UVMMC), and the community to coordinate referrals for cancer patients requiring support services.
Develops and maintains systems that facilitate patient access to Cancer Center programs and appropriate community‑based oncology resources.
Coordinates and develops supportive, educational, and survivorship‑focused programs based on identified patient and family needs.
Functions as the primary facilitator for oncology-related group sessions and for surveys and assessments required for accreditation, as applicable.
Participates regularly in multidisciplinary patient conferences providing information regarding follow-up, referrals, etc.
Establishes systems for follow-up with oncology patients such as telephone follow-up to ensure that services provided are meeting patient, Cancer Center, and community needs.
Assists patients and families with plan-of-care concerns and options, including but not limited to arranging transportation and lodging; applying for prescription assistance programs; and navigating insurance coverage for medical supplies, care, and medications.
Develops and implements strategies to strengthen oncology‑focused networking with community services within Clinton, Essex, and Franklin Counties.
Provides comprehensive psychosocial assessment and intervention for patients admitted to the inpatient medicine unit, including identification of social determinants of health impacting hospitalization, recovery, and discharge planning.
Participates in interdisciplinary rounds on the inpatient medicine unite, as well as swing bed long-stay meetings, collaborating with physicians, nursing, case management, therapy services, and allied health professionals to support care planning, complex discharge needs, and transitions of care.
Provides discharge planning and transitional care support from admission through discharge, ensuring safe and appropriate post‑hospital care planning through direct communication with patients and families.
Supports the swing bed program through participation in admissions, psychosocial assessments, care planning, and discharge planning for post‑acute and rehabilitation patients.
Participates in interdisciplinary swing bed care conferences and long‑stay reviews as indicated, contributing psychosocial insight related to patient adjustment, family dynamics, goals of care, and discharge barriers.
Coordinates referrals and services for inpatient medicine and swing bed patients, including home health, hospice, skilled nursing facilities, rehabilitation services, durable medical equipment, transportation, and community‑based supports.
Establishes and maintains collaborative working relationships with community agencies, post‑acute providers, and regional service partners to ensure continuity of care following inpatient or swing bed discharge.
Identifies patients at high risk for readmission and collaborates with interdisciplinary teams and organizational readmission‑reduction initiatives to address psychosocial contributors to avoidable hospital utilization
Other duties as assigned.