The Social Worker will conduct complete assessments, establish appropriate plans, and initiate interventions within desired timeframes. They will collaborate and negotiate effectively with patients, families, and the healthcare team to achieve patient and organizational goals related to care needs, choices, and satisfaction during discharge planning and care transitions. The role involves utilizing patient/family strengths in problem-solving, involving them in decision-making from admission throughout the hospital stay. This position provides social work services including psychosocial assessment, screening, needs evaluation, intervention, follow-up, and discharge planning. Interventions will be implemented based on assessments, consistent with available resources and payer networks. The Social Worker will participate as part of the multi-disciplinary health care team to develop safe and timely coordination of care, including post-acute placement, palliative/hospice services, medical equipment, home healthcare, outpatient follow-up, mental health resources, and other community resources. They will advocate for patient involvement in the plan of care and coordinate interventions with other team members. Maintaining knowledge of healthcare regulations, reimbursement issues, length of stay impacts, and community resources is essential. The role includes completing UM activities, providing clinical updates to payers, collecting data, supporting UM activity, and managing avoidable delays. Delivering CMS regulatory notices within established timeframes is also required. Effective communication with the healthcare team, partnership with RN Care Managers and unlicensed support personnel, and active participation in MDR are key. The Social Worker will work closely with medical staff, hospital departments, and ancillary services to resolve discharge barriers, expedite care delivery, and implement/report care coordination, discharge planning, and utilization management activities. Maintaining up-to-date knowledge of community resources, legislation, and regulations impacting healthcare delivery and educating patients/families on these issues is crucial. The role involves connecting patients to appropriate agencies for suspected abuse/neglect, domestic violence, guardianship, and other social matters. Providing resources for timely discharge and appropriate links with post-acute care providers is expected. Support and connection to services such as bereavement, loss, ethical issues, advanced directives, and end-of-life issues will be provided. Collaboration with community agencies and institutions for continued care planning and intervention coordination is necessary. The Social Worker will provide resources and education to patients and families regarding community social services. Effective communication with patients, families, healthcare team members, and community agencies to resolve issues impacting continuity of care (e.g., prior-approvals, application requirements, transfer paperwork) is required. Documentation will be completed according to department and program protocols. The role involves managing patient stay progression to optimize Length of Stay (LOS) and ensure appropriateness of assigned Level of Care. Managing patient care across the continuum to decrease unnecessary readmissions and coordinating care within an ACO environment to facilitate patient outcomes through in-network care coordination are key responsibilities. Site-specific goal achievement is expected. Participation in new staff orientation and/or social work student education is required. Education to patients/families regarding Advance Directives for healthcare decision-making and assistance with their execution is part of the role. Participation in legal proceedings as necessary to secure legal decision-makers is also required. Maintaining professional standards and responsibilities for professional practice according to accreditation, hospital, system, state, and NASW Standards and Code of Ethics is mandatory. Completing all required continuing education to maintain licensure and increase knowledge within the area of practice specialty is essential. The Social Worker must demonstrate knowledge and skills to provide care appropriate to the age of patients served, understanding principles of growth and development over the life span and assessing data to identify patient needs relative to age-specific requirements.
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Job Type
Full-time
Career Level
Mid Level