Social Worker PRN - Prov Care Management - Providence

USA Health•Mobile, AL

About The Position

The Social Worker works in an acute-care setting with physicians, bedside nurses, utilization-management specialists, and other clinical professionals to help patients and families transition effectively to the next level of care. The role assesses discharge needs, develops individualized discharge plans, connects patients with resources and services, and supports continuity of care. The Social Worker evaluates social determinants of health and high-utilizer and readmission risks, coordinates with community agencies, and documents assessments and plans. The position does not involve direct patient care responsibilities. Employees must work at least 20 hours per week (0.50 FTE or greater) to qualify for benefits.

Requirements

Master's degree in social work from an accredited institution; or a bachelor's degree in social work and two years of social work experience; or a bachelor's degree in a related field and three years of social work experience.
Licensure as a Social Worker in the state of Alabama.
A comparable combination of education and experience may substitute for the stated education and experience requirements.
Ability to establish and maintain effective working relationships and communicate with clients, staff, and community-agency representatives.
Excellent listening and communication skills.
Ability to communicate effectively orally and in writing.
Strong interpersonal and customer-service skills.
Ability to perform essential functions with minimal supervision.
Ability to work the defined schedule and overtime as required.

Responsibilities

Work with clinical professionals to help patients and families transition to the next level of care.
Perform initial discharge-planning assessments within 24 hours of admission, comparing baseline function with discharge needs.
Collaborate with patients, families, physicians, therapy services, nursing, utilization review, and other departments to formulate discharge plans.
Provide patients and families with resources based on insurance options and individual needs.
Send referrals to home health, skilled nursing facilities, long-term care, LTACH, DME, inpatient rehabilitation facilities, and other facilities; provide electronic medical record information supporting medical necessity.
Reassess patients when their condition or patient/family needs change.
Act as a resource for patient information to support continuity of care.
Confirm medications, transportation, and necessary equipment are arranged when finalizing discharge plans.
Document discharge plans and assessments in accordance with department policy.
Support RN case-management interdisciplinary rounds or conferences and communicate the discharge process during rounds.
Document avoidable days to help leadership identify performance-improvement opportunities.
Establish patient and provider goals and determine next steps for a positive experience and transition of care.
Evaluate high-utilizer inpatients—four or more hospitalizations in six months—for potential readmission risks using electronic medical record risk scoring.
Evaluate social determinants of health and differences between initial assessment and discharge needs; provide resources to help reduce readmission risk.
Complete readmission assessments within 24 hours of readmission and place appropriate referrals when opportunities to reduce further readmissions are identified.
Collaborate with outside agencies and community case-management programs to develop individual plans of care to reduce readmissions.
Perform discharge-planning assessments upon admission for self-pay patients and other patients identified by a healthcare team member as having specific discharge needs.
Assist with medication access, nursing home and rehabilitation placement, Veterans' Administration transfers, mental health referrals, transportation, probate commitments, home health, DME, hospice, facility transfers, and long-term care placement and transfers.
Collaborate with physicians, utilization review staff, and other healthcare team members to transition patients to the appropriate level of care.
Document actions in the medical record or department database.
Provide competent discharge-planning support for neonate, pediatric, adolescent, adult, and geriatric patient populations.
Follow compliance, confidentiality, infection-control, safety, and hospital policies and standards of performance.
Participate in educational programs, assigned committees, and performance-improvement activities.
Complete mandatory department, educational, and hospital requirements; maintain regular and prompt attendance and work the defined schedule and overtime as required.
Perform related duties as assigned.