Job Summary

Works with health care team that includes physicians, nurses, therapists, and other allied departments to care for patients. Provides appropriate assessment and interventions for the psychosocial and continued care needs of patients and families and including the recommendations of team members. Coordinates utilization of resources in the most cost-effective manner to meet patient’s ongoing physical, psychosocial and continuing care needs

Job Duties Provides physicians and members of the interdisciplinary health care team with appropriate and timely biopsychosocial information related to the patient's need for medical care and evaluates the plan of care with changing conditions, additional information or upon request and referral.Identifies patient's psychosocial needs in collaboration with the health care team and implements plan of care and appropriate intervention to meet identified needs.Reviews medical record, interviews patient and family members or responsible party.Discusses case with the multidisciplinary team to develop and implement appropriate interventions.Assesses patient and family level of understanding of diagnosis and treatment and determines ability to comply with medical recommendations.Provides intervention to maximize compliance with treatment plans.Evaluates patient psychosocial, living situation, available supports, and incorporates treatment team recommendations for post discharge care.Seeks clarification of information as needed and follows up on outstanding information that impacts final plans and referrals needed.Educates patients and families of applicable resources, limitations and relevant financial issues of the services to meet patient needs.Coordinates internal and external services to meet the identified needs of patient.Communicates to patients, families, and multidisciplinary team in a timely manner when the changes in patient care needs require a change in the expected discharge plan, available community resources, and alternatives that are appropriate to meet the revised plan of care.Referrals are completed to appropriate community resources in a timely manner to ensure patient discharges are not delayed due to avoidable actions.Assists with completion of resource forms as needed to facilitate timely services to patients.Ensures patients are offered choice of vendors in selection of referrals to meet post acute needs.

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.

Position Details To be discussed during interviewTravel -Less than 25%- may be required for meetings and patient home visits.Advanced Care PlanningWork from home opportunity. Seeking compassionate and collaborative LSW to be a core member of the Geisinger at Home Palliative Interdisciplinary team.

Geisinger cares about not only its patients and members but also about you and your family. We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally. We believe in creating a diverse and inclusive environment where all employees can be their authentic selves. To learn more: https://jobs.geisinger.org/diversity 

Benefits of working at Geisinger:

Full benefits (health, dental and vision) starting on day one Three medical plan choices, including an expanded network for out-of-area employees and dependents  Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA)  Company-paid life insurance, short-term disability, and long-term disability coverage  401(k) plan that includes automatic Geisinger contributions  Generous paid time off (PTO) plan that allows you to accrue time quickly  Up to $5,000 in tuition reimbursement per calendar year  MyHealth Rewards wellness program to improve your health while earning a financial incentive  Family-friendly support including adoption and fertility assistance, parental leave pay, military leave pay and a free Care.com membership with discounted backup care for your loved ones  Employee Assistance Program (EAP): Referrals for childcare, eldercare, & pet care. Access free legal guidance, mental health visits, work-life support, digital self-help tools and more.  Voluntary benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life and pet and legal insurance   Education Master's Degree-Social Work (Required) Certification(s) and License(s) Licensed Social Worker - Default Issuing Body Skills Working Independently; Organizing; Behavioral Therapy Management; Assessment And Diagnosis; Intake Assessments; Patients Rights; Psychotherapy; Social Work About Geisinger

Founded more than 100 years ago by Abigail Geisinger, the system now includes ten hospital campuses, a 550,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,700 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and Twitter.

Our Commitment to Diversity, Equity and Inclusion

Geisinger values who you are, where you are from, and where you are going. We seek out people of various backgrounds and cultures with unique abilities, non-traditional career paths and ambitious aspirations. We are an Affirmative Action, Equal Opportunity Employer. Women and Minorities are encouraged to apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status. Read more about Our Commitment to Inclusive Recruiting.

Our Vision & Values

Everything we do is about making better health easier for our patients, our members, our students, our Geisinger family and our communities.

KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.

EXCELLENCE: We treasure colleagues who humbly strive for excellence.

LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.

INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.

SAFETY: We provide a safe environment for our patients and members and the Geisinger family.

Our Benefits

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.