Social Worker Rehab and Nursing

Corewell Health•Grand Rapids, MI

50d•Onsite

About The Position

To work collaboratively with members of an interdisciplinary team in order to assist patients and families with complex psychosocial needs. These interventions may include, but are not exclusive to: alternate site coordination, discharge planning, addressing all forms of identified abuse/neglect, adoption, substance use disorders, assisting with end of life decisions, providing appropriate referral resources, bereavement support, adjustment counseling, facilitating guardianships and behavioral health concerns (including psychiatric transfers). Essential Functions - LMSW Conducts psychosocial assessments with patient and or family to assist with identified psychosocial needs or who may be identified to require an alternate site of care post discharge and executes a plan. Communicates with alternate sites of care and/or community agencies in an effective and timely manner, to best address the patient's needs. Completes and documents the assessment and plan in the electronic medical record, accurately reflecting the patient's current condition, situational factors, transition of care needs and psychosocial imperatives. Provides consultation and resources to members of the healthcare team. Responsible for maintaining relevant and current knowledge of community resources. Participates or assists in department, regional, or statewide stakeholder committees, projects etc., as assigned/requested. Develops and maintains current knowledge of federal and state regulations as they pertain to role. Provide short term therapeutic support as appropriate for setting and location. or- Essential Functions - BWS Competently gathers information using assessment skills to identify physical, psychosocial, financial and environmental health care needs of the patient/resident. Assess and identify appropriate resource utilization, level of care and treatment options to develop a plan of care that will impact quality outcomes in a cost effective manner. Collaborates with the patient/resident, family and health care team to promote quality care, prevent delay in discharge and complications to improve outcomes. Work with the patient and physician to develop a plan of care that meets their needs and will avoid duplication and or fragmentation of services. Ensure appropriate use of ancillary services providing guidance and direction and implementing modification to the plan of care as needed. Efficiently documents assessments, clinical findings, completed tasks, plan for treatment and progress toward goals for discharge. Keep accurate record of patient/family contact and team consultation. Works to actively facilitate an appropriate level of care for discharge and educate the patient on the progress of the discharge plan and the safety and benefits of the plan. Monitor, evaluate, and coordinate referrals from multiple sources, while measuring patient care outcomes, interpreting reports and addressing data from sources to better serve and impact the patient and their adjustment to illness and treatment. Actively promotes frequent communication between all team members, providers, patients and family members to ensure a smooth transition from one level of care to another. Share and educate on community resources, support systems and available benefits. Maintain communication with providers delivering care to ensure consistency in communication to patient/resident and family. Demonstrate self directed, self motivated, responsible behavior recognizing when there is a need for adjustment and flexibility in professional function. Respect confidentiality of all parties involved in the patient/resident care process and utilize the professional skills of other team members and disciplines for improvement in the discharge plan. Actively participates in safety initiatives and risk mitigating measures where appropriate and completes all position and unit safety related competencies and requirements on a timely basis. Performs other duties as assigned.

Requirements

Master's Degree Social Work
LIC-Master Social Worker (MSW-Master) - STATE_MI State of Michigan Upon Hire
Bachelors Degree in Social Work: Exceptions for persons without a social work degree can be made for those who have a human services degree and carry a current social work license

Nice To Haves

2 years of relevant experience healh care related experience post obtaining Master's Degree in Social Work
Care management experience
Experience in individual, family assessment, crisis intervention, grief and loss counseling, and discharge planning preferred
1 year of experience Supervised social work experience in health care setting working directly with individuals.
1 year of experience skilled nursing home process and procedure
1 year of experience mental health, substance abuse assessment and treatment
1 year of experience community resources and discharge planning
3 years of experience Hospital or Nursing Home Social work

Responsibilities

Conducts psychosocial assessments with patient and or family to assist with identified psychosocial needs or who may be identified to require an alternate site of care post discharge and executes a plan.
Communicates with alternate sites of care and/or community agencies in an effective and timely manner, to best address the patient's needs.
Completes and documents the assessment and plan in the electronic medical record, accurately reflecting the patient's current condition, situational factors, transition of care needs and psychosocial imperatives.
Provides consultation and resources to members of the healthcare team.
Responsible for maintaining relevant and current knowledge of community resources.
Participates or assists in department, regional, or statewide stakeholder committees, projects etc., as assigned/requested.
Develops and maintains current knowledge of federal and state regulations as they pertain to role.
Provide short term therapeutic support as appropriate for setting and location.
Competently gathers information using assessment skills to identify physical, psychosocial, financial and environmental health care needs of the patient/resident.
Collaborates with the patient/resident, family and health care team to promote quality care, prevent delay in discharge and complications to improve outcomes.
Efficiently documents assessments, clinical findings, completed tasks, plan for treatment and progress toward goals for discharge.
Monitor, evaluate, and coordinate referrals from multiple sources, while measuring patient care outcomes, interpreting reports and addressing data from sources to better serve and impact the patient and their adjustment to illness and treatment.
Actively promotes frequent communication between all team members, providers, patients and family members to ensure a smooth transition from one level of care to another.
Demonstrate self directed, self motivated, responsible behavior recognizing when there is a need for adjustment and flexibility in professional function.
Actively participates in safety initiatives and risk mitigating measures where appropriate and completes all position and unit safety related competencies and requirements on a timely basis.
Performs other duties as assigned.

Benefits

Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status

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