Social Worker Weekend MSW

Independence Health System Careers•Greensburg, PA

About The Position

Essential Job Functions Assesses, plans, implements, coordinates, monitors, and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes. Completes patient assessments to identify barriers to discharge with a focus on social determinants of heath, patient’s ability for self care, or any potential post-hospital services that may be required at discharge. Identifies any psychosocial, clinical, cultural, spiritual, or financial barriers that may impede a safe effective transition from the hospital. Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes. Initiates care coordination strategies that are evidence-based and outcome focused. Collaborates with the multidisciplinary team to formulate a safe discharge team. Utilizes the readmission risk tool to identify barriers to effective discharge plan. Identifies patient care requirements by establishing personal rapport with patients, families, and caregivers. Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients and families. Ensures safe and effective transitions of care that help to promote positive health care outcomes while focusing on social determinants of health that affect a patient’s overall well being. Promotes patient's independence by working to transition to the least restrictive level of care and establishing goals of care with patient, family, and caregiver. Has knowledge of resources in the area such as post-acute providers, home health agencies, hospice, LTACH, IP rehab, assisted living, skilled nursing facilities, DME, etc. Arranges for post hospital services prior to discharge and ensures they are done timely to avoid delays in discharge. Acts as the liaison between the patient, hospital, and post hospital services. Maintains a safe and clean working environment by complying with environmental procedures, rules and regulations. Demonstrates competencies of critical-thinking skills for transitioning complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally sensitive discharge planning. Maintains professional knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies. Protects patients and employees by adhering to infection-control policies and protocols Assures care coordination that takes into account patients' values, needs, preferences and their choice to self-direct care. Maintains patient confidence and protects operations by keeping information confidential and abiding by HIPPA standards. Puts the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time. Effectively manages transitions involving comprehensive planning, targeted outreach and the timely transfer of information between parties critical to the transition. Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes. Facilitates the flow of care to expedite an appropriate discharge and prevent readmissions. Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team continuous quality improvement and problem-solving methods. Ensures complete, accurate, timely and appropriate documentation of patient assessment, and any information for the discharge plan. Communicates discharge plan to members of the health care team via attendance at SIBR rounds, concurrent documentation, and verbal communication. Evaluates and projects discharge planning needs and coordinates post-acute care needs of patient in assigned case load. Coordinates post-hospital needs in a timely and effective manner. Applies advanced interpersonal skills in negotiating appropriate plan of care needs for assigned patient population. Acts as a resource/consultant to internal customers for extensive knowledge of community resources and expertise in accessing social/community systems. Reviews the laws and regulations that influence the practice of social work. Has working knowledge of Advanced Directives, HIPAA, and health care proxy formats. Works with legal team for potential guardianship or adoption cases. Other duties as assigned

Requirements

Master’s Degree in Social Work.
Minimum of 1 year of experience in Case Management/Social Work or comparable prior work experience such as inpatient acute care, hospice, home health, post-acute care facilities, inpatient rehabilitation, LTACH, etc.
Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects.
Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.
Knowledge of Payor/Insurance Benefits
Functional Skills on PC and Related Software (Microsoft Office)
Knowledge of basic Office Equipment such as copier, fax machine, etc.
Act 33 with renewal
Act 34 with renewal
Act 73 FBI Clearance with renewal

Nice To Haves

Case Management Certification preferred
LSW or LCSW preferred

Responsibilities

Assesses, plans, implements, coordinates, monitors, and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes.
Completes patient assessments to identify barriers to discharge with a focus on social determinants of heath, patient’s ability for self care, or any potential post-hospital services that may be required at discharge.
Identifies any psychosocial, clinical, cultural, spiritual, or financial barriers that may impede a safe effective transition from the hospital.
Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes.
Initiates care coordination strategies that are evidence-based and outcome focused.
Collaborates with the multidisciplinary team to formulate a safe discharge team.
Utilizes the readmission risk tool to identify barriers to effective discharge plan.
Identifies patient care requirements by establishing personal rapport with patients, families, and caregivers.
Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients and families.
Ensures safe and effective transitions of care that help to promote positive health care outcomes while focusing on social determinants of health that affect a patient’s overall well being.
Promotes patient's independence by working to transition to the least restrictive level of care and establishing goals of care with patient, family, and caregiver.
Has knowledge of resources in the area such as post-acute providers, home health agencies, hospice, LTACH, IP rehab, assisted living, skilled nursing facilities, DME, etc.
Arranges for post hospital services prior to discharge and ensures they are done timely to avoid delays in discharge.
Acts as the liaison between the patient, hospital, and post hospital services.
Maintains a safe and clean working environment by complying with environmental procedures, rules and regulations.
Demonstrates competencies of critical-thinking skills for transitioning complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally sensitive discharge planning.
Maintains professional knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
Protects patients and employees by adhering to infection-control policies and protocols
Assures care coordination that takes into account patients' values, needs, preferences and their choice to self-direct care.
Maintains patient confidence and protects operations by keeping information confidential and abiding by HIPPA standards.
Puts the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time.
Effectively manages transitions involving comprehensive planning, targeted outreach and the timely transfer of information between parties critical to the transition.
Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes.
Facilitates the flow of care to expedite an appropriate discharge and prevent readmissions.
Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team continuous quality improvement and problem-solving methods.
Ensures complete, accurate, timely and appropriate documentation of patient assessment, and any information for the discharge plan.
Communicates discharge plan to members of the health care team via attendance at SIBR rounds, concurrent documentation, and verbal communication.
Evaluates and projects discharge planning needs and coordinates post-acute care needs of patient in assigned case load.
Coordinates post-hospital needs in a timely and effective manner.
Applies advanced interpersonal skills in negotiating appropriate plan of care needs for assigned patient population.
Acts as a resource/consultant to internal customers for extensive knowledge of community resources and expertise in accessing social/community systems.
Reviews the laws and regulations that influence the practice of social work.
Has working knowledge of Advanced Directives, HIPAA, and health care proxy formats.
Works with legal team for potential guardianship or adoption cases.
Other duties as assigned