Provides assessment and intervention to assist clients/families to improve social and economic difficulties interfering with health and wellness through use of casework process and principles, strategies, and community resources.  Provides professional discharge planning services through assessments, and coordination of post hospital care needs to patients and their families; providing them with resources and choices to effectively link them to the needed level of emotional, medical and spiritual care. Receives referrals for individuals from at-risk populations from interdisciplinary team members. 

 Essential Functions and Responsibilities as Assigned:

1.      Performs assessment on assigned patients, with focus on identifying those with complex psych-social or financial issues, placement needs and on the next business day after admission.

2.      Identifies and assesses barriers early in the patient’s stay, formulating a plan with the patient, family, internal and external members of the healthcare team, payers, and community resources (e.g., LOS barriers to D/C).

Assesses patient and family needs for support and community service needs (Meals on Wheels, Council on Aging, substance abuse etc.); educates and refers them to community resources, access to services, and establishes rapport with other agencies.

4.      Assesses risk of readmission for specified patient populations and initiates assigned interventions that will enhance the patient’s ability to successfully transition along the care continuum.

5.      Identifies the need for, arranges, and participates in family care conferences; participates in interdisciplinary conferences and provides consultation for patient, families, and clinical staff (e.g., attends care conferences/unit rounds/huddles).

6.      Uses knowledge of insurance benefits and coverage guidelines to maximize appropriate utilization of resources.

Documents in the EMR: assessment, plans, interventions, barriers, and reassessments as necessary to facilitate discharge and/or transitions; ensures all pertinent information is transferred to post-acute agency.

8.      Works collaboratively with the RN Care Manager/Supervisor, other disciplines, and internal and external members of the healthcare team to ensure a safe, appropriate, and timely transition to the next level of care, taking into consideration the patient’s available resources and preferences.

9.      Performs other related duties as required and directed.

Required:

Clinical Licensed Bachelor’s Social Worker

 Preferred: 

Clinical Licensed Master’s Social Worker

·         Discharge planning experience preferred.

Minimum of three (3) years clinical experience in a hospital setting preferred. Additional Information Schedule: Full-time Requisition ID: 25000544 Daily Work Times: 8 am - 4:30 pm Hours Per Pay Period: 80 On Call: No Weekends: No