At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. Job Description **SUMMARY** Responsible for providing appropriate interventions and discharge planning services to patients and families. Facilitates a smooth transition for the patient throughout the continuum of care by accessing hospital, community and governmental resources. pragmatic in approaching End of Life and ethical issues. **This is a PRN position at Fairfield Hospital** **ESSENTIAL JOB FUNCTIONS** + Assesses constantly for best resource allocation with patient management activities both in hospital and community systems to advocate for cost containment without jeopardizing + patient quality efforts; Completes initial and ongoing assessment of the patient and family's response to the diagnosis, living environment and discharge planning needs; Identifies and reports appropriate discharge barriers and avoidable days in order to promote the resolution process within the hospital or community systems; Provides assessment for the source and significance of social, psychological, environmental, emotional, and economic factors that may contribute to the health and response to treatment of both inpatients of all ages and documents appropriately in the medical record + Actively coordinates patient and family interventions with the attending physician, patient, family, care managers, and other staff; Develops treatment plan based on the assessment and mutually agreed upon goals with the patient, family and physician; Develops a plan of intervention, which is integrated with the interdisciplinary treatment team to establish continuum of care in congruence with ethical and legal considerations; Advocates, mediates, and negotiates a cohesive plan for maintaining or improving social supports and patient safety + Evaluates the effectiveness of interventions and actions in relation to the intended goals of the discharge plan; Revises intervention strategies and discharge plan as necessary; Identify barriers in service delivery systems and advocate for change; Evaluate patient outcomes and participate in process improvement. Follows leading, standardized practices and processes related to Advance Care Planning. Supports and implements proactive practices to impact unnecessary LOS, supports readmission prevention utilizing a predictive readmission risk tool (and qualitative data as well) and application of appropriate interventions, supports denial prevention related to medical necessity through proactive progression of care and addressing/removing barriers (including tracking of avoidable days/delays) + Collaborate with interdisciplinary team to enhance quality of care and efficiency; Maintain a positive working relationship with healthcare team and community agencies and services; Assist interdisciplinary team in understanding significant social and emotional factors related to illness; Functions as a liaison for the patient and the facility both internally and externally. Maintains networks for professional growth and awareness; Works collaboratively with the health care team to facilitate the plan of care for inpatients and outpatients, as appropriate. + Assures chart documentation consistently meets the department and hospital standards for accountability and confidentiality; Recognizes legal responsibilities and identifies area of concern to Risk Management and Legal Services; Maintains current knowledge and is familiar with federal and state regulatory guidelines, institutional policies, and payer source policies; Documents interventions timely. + Advance Care Planning extends the compassionate ministry of Jesus and is integrated into the ministry’s Ethical and Religious Directive and is our duty as proponents of self-determination and informed consent. The social worker examines advance care planning documents ensuring they are current, and available to the healthcare team as part of the initial care management assessment for high-risk populations. Activates the advance care planning process as warranted, and consults with other disciplines to assist as needed. Promotes the understanding and use of advance care planning with other members of the healthcare team and ensures goals of care are respected. Reviews and documents patient care goals and identify the patient’s designated decision maker. Collaborates with other facility resources/care team members to assist as needed with ACP process completion. + Attends appropriate clinical and professional organizations, workshops and meetings, Stays abreast of community resources available to facilitate safe patient transitions of care, Remains current on clinical advancements related to primary patient population, Proactively seeks to understand areas/roles outside of immediate area/role within department. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation. **EMPLOYMENT QUALIFICATIONS** **Required Minimum Education:** 4 year/ Bachelors Degree Specialty/Major: Social Work **Preferred Education:** Graduate Degree (Masters) Specialty/Major: Social Work **Licensure/Certification** **Required:** Licensed Social Work (LSW) in state facility is located. **Minimum Years and Type of Experience:** 1 Year experience in Acute Care setting **Other Knowledge, Skills and Abilities Required:** Casework principles, including diagnosis, assessment, crisis intervention, and treatment planning; techniques in individual and family supportive counseling; knowledge of community resources, public assistance systems, Medicare/Medicaid; accepted professional, ethical, and regulatory standards within the existing medical community and professional organizations. Ability to prioritize many simultaneous demands and tolerate frequent interruptions. Self-awareness, professionalism, and good judgement when addressing emotional and confidential issues. Excellent verbal and written communication. Many of our opportunities reward* your hard work with: Comprehensive, affordable medical, dental and vision plans Prescription drug coverage Flexible spending accounts Life insurance w/AD&D Employer contributions to retirement savings plan when eligible Paid time off Educational Assistance And much more *Benefits offerings vary according to employment status All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com . If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com