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, appropriate interventions, follow-up, and discharge planning. Interventions will be implemented based on assessments, consistent with available resources and payer networks. The Medical Social Worker will participate 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 will advocate for patient involvement in the plan of care and coordinate interventions with other team members. Maintaining up-to-date knowledge of healthcare regulations, reimbursement issues, length of stay impacts, and community resources is essential. This role also includes completing UM activities, providing clinical updates to payers, collecting data, supporting UM activity, and managing avoidable delays. Delivering CMS regulatory notices within established timeframes is also a responsibility. Effective communication with the healthcare team is crucial, working in partnership with RN Care Managers and unlicensed support personnel to establish and implement a safe plan of care. The Medical Social Worker will serve as an active member of the MDR, working closely with medical staff, hospital departments, and ancillary services to identify and resolve barriers to discharge, expedite care delivery, and implement/report care coordination, discharge planning, and utilization management (UM) activities. They will maintain knowledge of community resources, legislation, and regulations impacting health care delivery, educating patients and families as appropriate. Connecting patients to appropriate agencies for suspected abuse/neglect, domestic violence, guardianship, and other social matters is required. Providing resources to patients and families for timely discharge and appropriate links with post-acute care providers and services is key. Support and connection to additional services such as bereavement, loss, ethical issues, advanced directives, and end-of-life issues will be provided. Collaboration with community agencies and institutions for continued care planning and intervention coordination is expected. Effective communication with patients, families, healthcare team members, and community agencies to resolve issues impacting continuity of care (e.g., prior-approvals, application requirements, transfer paperwork) is necessary. Documentation will be completed according to department and program protocols. The role involves managing patient stay progression to optimize Length of Stay (LOS) and ensure appropriateness of assigned Level of Care. Managing patient care across the continuum to decrease unnecessary readmissions and coordinating patient care within an ACO environment to facilitate patient outcomes through in-network care coordination are also responsibilities. Accountability for site-specific designated goal achievement is required. Participation in the orientation of new staff and/or education of social work students is expected. Education to patients/families regarding Advance Directives for healthcare decision-making and assistance with their execution will be provided. Participation in legal proceedings as necessary to secure legal decision-makers is required. Maintaining professional standards and responsibilities for one's own professional practice according to accreditation, hospital, system, state, and NASW Standards and Code of Ethics is essential. Completing all required continuing education to maintain licensure and increase knowledge within the area of practice specialty is mandatory. The incumbent must demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served, including understanding of growth and development principles and the ability to assess and interpret data reflective of patient status and needs based on age-specific requirements.
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Job Type
Full-time
Career Level
Mid Level