The medical social worker is responsible for promoting patient-centered care by evaluating psychosocial needs, providing community service coordination for identified patient populations, and providing support and crisis intervention where indicated. The social worker acts as a liaison between the patient and community resources/post-acute care providers. The social worker creates and facilitates timely implementation of discharge plans and arranges post-acute interventions identified in the plan of care. The social worker facilitates patient movement across the continuum of care and identifies, addresses, and tracks barriers to patient throughput. In partnership with RN CM, the social worker is responsible for ensuring the post-acute medical needs and level of care are appropriate The social worker will respond timely to referrals from RN CM or other staff when risk factors for social determinants of health are identified Perform thorough assessments and develop appropriate plans of care for high risk patients with discharge planning or psychosocial needs Perform proactive discharge planning Provideexpertisein post-acute services and community resources Identifyand address barriers to discharge and recovery, including financial, emotional, psychosocial, medical, spiritual Provide psychosocial support and resources Provide education to patients and caregiversregardingcommunity resources and post-acute level of care criteria, benefits, and coverage Assistin coordinating andfacilitatingfamily conferences Engage in community outreach and program development to support patient and caregiver needs Participate in interdisciplinary care planning process Maintain effective communication between members of the care team Provide expertise in ethics cases Assist patients and caregivers with end of life issues, from advance directives to grief support Provide psychosocial support to patients and caregivers for adjustment to patients' chronic and/ or terminal illness/death
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Job Type
Part-time
Career Level
Mid Level
Industry
Hospitals
Number of Employees
5,001-10,000 employees