About The Position

Comprehensively plans for services for a targeted population. Responsible for psychosocial assessments, crisis intervention, discharge planning, and coordination of referrals and resource information to patients and families in need of assistance. Independently identifies complex patients as well as receives referrals from nursing and other ancillary staff. Provides an array of social work services to patients and families to promote understanding and resolution of problems related to environmental stress, physical illness, interpersonal conflicts, and other psychosocial issues. Adheres to the patient experience initiatives and champions customer service. Works collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum at the appropriate level of care.

Requirements

  • Master’s Degree in Social Work required
  • Licensed Social Worker in North Carolina required
  • 1 year experience in Social Services, Home Health, Hospice or Acute Care setting required
  • Must have behavioral health, mental health, and substance abuse experience.
  • Must have experience with children/youth.
  • Light carrying and lifting may be required
  • Walking may be required to access all areas of the Medical Center
  • Ability to effectively communicate orally to patients, family members, personnel and physicians
  • Visual acuity to proofread hand or typewritten materials
  • Manual ability to use telephones and computer keyboard

Nice To Haves

  • Professional Certification in Case Management or Social Work (CSW, CCM, or ACM) preferred
  • Paramedic experience is highly preferred.
  • Acute Care Case Management experience preferred

Responsibilities

  • Conducts face-to-face interviews with patients and family members to develop therapeutic relationships and obtain psychosocial and financial information necessary for the facilitation of appropriate discharge planning
  • Performs proactive screenings and assessments for patients’ clinical, psychosocial, and discharge planning needs
  • Documents assessment, the on-going plan, case progress, intervention(s), and reassesses patients as needed
  • Initiates referrals and recommend consults to enable patient to be prepared for safe and timely discharge or transfer
  • Assists patient/family in coping with hospitalization, disability, and chronic/terminal illness
  • Utilizes communication, negotiation, and advocacy skills with patients, family, healthcare team and community
  • Provides information, education to patient/family on community resources and options for post-acute care appropriate to the age of the patient served
  • Carries out discharge planning activities to include providing arrangements for Home Health, Hospice, Home Infusion, DME, Outpatient Hemodialysis, Rehab, LTAC, Assisted Living, Rest Home and Skilled Nursing Facility placements
  • Provides alternate plan of care options at the appropriate level of care based on patient/family needs and in collaboration with physician and/or designated team members
  • Serves as a resource for processing issues such as guardianship, abuse, neglect, power of attorney, healthcare surrogate, advance directives or psychiatric involuntary commitment.
  • Initiates/completes forms required for post-acute placement.
  • Serves as a reliable resource for the Acute Care Nurse Navigator for difficult placements, information on Medicaid and disability, and Department of Social Service Referrals
  • Consults with the Acute Care Nurse Navigator when clinical explanation of disease processes, clarification of physicians’ orders, and other pertinent information is needed to determine, safe appropriate discharge plan
  • Other duties as assigned

Benefits

  • Exceptional healthcare
  • Caring employees are committed to integrity, patient-centeredness and excellence throughout the entire healthcare process.
  • Improve the quality of every life we touch.
  • Diverse team of doctors, nurses and staff work together to create a better experience for every patient, every time.
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