Social Worker (MSW) - Full time Days

Interacts with patients, family members, healthcare professionals, and community and state agencies. The Social Worker serves as a liaison between the hospital and community agencies or facilities for the exchange of clinical and referral information. Identifies high risk patients from a psychosocial/financial perspective, assesses the psychological needs of patients and families and provides information, support, counseling, care management, and referrals to appropriate resources. Works collaboratively with the interdisciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum. Resolves psychosocial patient care issues and develops and implements a complex patient transition/discharge plan. Participates in the screening of participants and evaluates psychosocial surveys to ensure appropriate and successful group participation. Provides support in developing the skills necessary for integrating lifestyle changes into daily life. Participates in the interdisciplinary team development of a plan of care for each participant. Participates in the monitoring, documentation, and communication of the participant's response to the interdisciplinary team plan of care. Monitors group support adherence for all participants and provides additional explanation of guidelines on an individual basis as needed. Assesses, plans and initiates patient plan of care. Facilitates and coordinates details of placement and actual discharge to appropriate agencies. Initiates and monitors completeness, accuracy and timeliness of all documentation. Provides documentation of initial assessments and reviewing of all referrals for accuracy and content prior to discharge. Reports potential risk or quality management. Escalates issues to resource as necessary to resolve barriers through appropriate administrative and medical channels. Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.