Position Summary Facilitates communication and coordination between patients, families, and referral sources to maximize patient functioning in the community. Exercises independent judgment and discretion in patient management decisions, within established guidelines, based on organizational policies, procedures, and the professional code of ethics. Performs duties with minimal supervision. Position Specific Responsibilities Assess patients’ psychosocial, financial, environmental, and community needs, as documented in the initial social work assessment, Plan of Care (POC), clinical records, and team meeting notes. Provide direct and indirect social services support for patients and families in all service settings (homes, long-term care facilities, hospitals). Deliver crisis intervention and supportive counseling for patients and families. Complete all documentation in compliance with federal/state regulations and policies to ensure regulatory compliance. Actively participate as a member of the interdisciplinary team, providing input to support patient/family care objectives. Attend team meetings, contribute to care planning, and collaborate with colleagues to coordinate patient/family services. Provide consultation and assistance to colleagues, administration, patients/families, and community partners as needed. Support level-of-care changes and discharge planning for patients and families. Respond promptly to referrals from the interdisciplinary team and community for social services needs. Accept assignments consistent with education, experience, and competence. Promote teamwork, effectiveness, and efficiency through a cooperative and professional attitude.
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Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees