Social Worker PRN Osborn
About The Position
The Social Worker is accountable for an assigned caseload and works collaboratively with patients, caregivers, healthcare providers, and external partners to coordinate care and share complex information across the healthcare continuum. The role supports smooth transitions of care and positive patient and family experiences. The Social Worker collaborates with patients and caregivers early in an inpatient or outpatient episode to prepare for discharge, addressing supportive care, end-of-life decisions, community resources and programs, goal setting, and long-term planning. The position identifies and coordinates safe post-acute interventions, assesses readmission risks and barriers to outpatient care, and assists patients with advance directives. It facilitates timely transitions to appropriate levels of care, communicates discharge plans and financial obligations, coordinates handoffs, and provides information to payers for service authorization. The role also promotes integrated communication among care-team members, maintains caseloads and case-management metrics, and may advocate for patients throughout the care continuum.
Requirements
- Master's degree in Social Work.
- One year as a Licensed Social Worker and/or successful completion of a health-related field placement in a master's-level Social Work program.
- Licensed Social Worker (LSW), Licensed Clinical Social Worker (LCSW), or Licensed Master Social Worker (LMSW) license.
Nice To Haves
- Two years of case-management experience.
- Three years as a Licensed Social Worker.
- Experience managing behavioral health patients.
- Certified Case Manager certification.
Responsibilities
- Collaborate with patients and caregivers early in inpatient or outpatient care to prepare for discharge, including supportive care, end-of-life decisions, community resources and programs, goal setting, and long-term planning.
- Interview patients and identify and coordinate safe post-acute interventions, including pre- and post-discharge home visits, behavioral health service coordination, guardianship, repatriation, adoptions, CPS, APS, and ALTAC.
- Assess readmission risk and outpatient barriers to care, including home support, medication management, and expectations.
- Initiate and assist patients with advance directives.
- Facilitate smooth, timely transitions from acute care to the appropriate level of care by communicating clinical information and care plans among hospitalists, specialists, primary care providers, and other key providers.
- Communicate financial obligations and other discharge-plan information to patients, families, and MPOAs.
- Ensure effective transitions and final handoffs to the next appropriate level-of-acuity case-management team.
- Communicate inpatient-stay and discharge-plan information to payers to obtain authorization for services.
- Promote collaboration and communication among healthcare team members, patients, clients, families, and significant others to ensure integrated care services are appropriate and beneficial from admission through discharge.
- Participate in developing and maintaining case-management metrics.
- Maintain and manage an assigned caseload.
- May act as a patient advocate and resource for physicians, patients, and families; facilitate communication and monitor care quality using standards of care and evidence-based practice guidelines.
- Advocate using knowledge of applicable laws, regulations, government and insurance benefits, practice guidelines, and standards of practice.
- Perform other related duties as assigned or requested.
