Social Worker, Home Health Northwest Region

Allina Health

11d • $31 - $50

About The Position

The Social Worker provides patients and families with psychosocial support to help them cope with chronic, acute, or terminal illnesses. Services include advising family caregivers, providing patient education and counseling, and making referrals for other services. The role may also include care and case management or interventions to promote health, prevent disease, and address barriers to healthcare access.

The Social Worker conducts psychosocial assessments and develops individualized intervention and care plans, identifies patients needing services, and supports and counsels patients and families. The role coordinates complex transitions with patients, families, healthcare teams, and community providers; documents progress in the electronic medical record; and collaborates with interdisciplinary teams and community resources to move care plans forward. The Social Worker also advocates for patient rights, addresses social and financial needs, supports appropriate transitions and referrals, and may participate in readmission prevention and length-of-stay management.

This position is based in Allina Health’s Home Care department in the Northwest Region. It is a 1.0 FTE position with 40 hours per week, working an 8-hour day shift with no weekend rotation. The work is classified as sedentary, involving lifting up to 10 pounds occasionally and negligible weight frequently.

Requirements

• Bachelor’s degree in Social Work.
• Licensed Social Worker credential from the Minnesota Board of Social Work.
• Licensed Social Worker credential from the Wisconsin Department of Safety & Professional Services if working in Wisconsin or interacting with Wisconsin patients remotely; both state licenses may be required depending on services provided in the department.
• Valid driver’s license upon hire. Minnesota and Wisconsin residents must obtain a valid license in their state of residence within 60 days of employment for positions in Home Care, Palliative Care Community, Senior Health CoCare, and System Complex Care Management.

Nice To Haves

• Master’s degree in Social Work.
• Experience in an acute care setting.
• Two or more years of social work experience.

Responsibilities

• Deliver professional social work services, including psychosocial assessments and intervention planning.
• Identify patients requiring social work assessment and intervention through high-risk screening, interdisciplinary team meetings, and individual referrals.
• Assess bio-psycho-social issues based on age, population, and health-specific needs and develop individualized plans of care.
• Provide support and counseling to patients and families.
• Provide information and assistance for identified financial or social needs.
• Coordinate complex transition plans with patients, families, healthcare teams, and community providers.
• Use the electronic medical record to monitor, document, and communicate patient progress toward goals and progression of the social work plan.
• Collaborate and communicate with interdisciplinary teams to anticipate needs and advance the plan of care.
• Provide patients and families with support and information regarding transition plans.
• Maintain knowledge of government and private payer networks and services to support appropriate transitions.
• Coordinate patient care with community and healthcare resources based on identified needs.
• Advocate for patients and families by supporting patient rights and access to protective services.
• Apply awareness of patient rights and ethical decision-making, and provide advocacy for patients and families.
• Ensure appropriate mandated reporting of vulnerability or suspected abuse.
• May participate in care-system processes intended to prevent readmissions.
• Plan and participate in transition conferences with patients and families.
• Use tools and technology to identify and intervene with patients at risk for readmission.
• Ensure complete clinical handoffs for at-risk patients, which may include referrals.
• May collaborate with the healthcare team to promote appropriate length of stay.
• Use tools and technology to support appropriate length-of-stay management.
• Facilitate timely referrals and transfers of information.
• Perform other duties as assigned.

Benefits

• Medical and dental coverage.
• PTO/time away.
• Retirement savings plans.
• Life insurance.
• Short-term and long-term disability coverage.
• Voluntary benefits, including vision, legal, and critical illness coverage.
• Tuition reimbursement or continuing medical education, as applicable.
• Student loan support benefits to navigate the Federal Public Service Loan Forgiveness Program.
• Well-being dollars, well-being navigators, programs, activities, articles, videos, personal coaching, and tools.

What This Job Offers

• Job Type: Full-time