Basic Function: Assess, plan, implement and evaluate individual healthcare needs. Integrate Discharge Planning, Utilization Review and Performance Improvement activities at the patient, hospital and system levels. Efficiently and effectively anticipates, identifies and resolves issues through utilization review and discharge planning processes. Collaborates with the ED physicians and clinical staff to ensure resource utilization is appropriate to the patient’s clinical needs and within covered benefits. Works with patients, families, internal departments and external agencies to provide smooth, timely transition of care across the continuum. Activities will be documented as per policy. Information will be analyzed, tracked, trended and shared with the appropriate medical dental staff or hospital department as needed. Ensures that outcome management (data collection through analysis) information is accurate, communicated and evaluated for process improvement potential. Provide psychosocial support to patient and/or family in crisis, with special needs and/or coordination and referral. Requirements: Master's degree in Social Work is required. NYS LMSW or LCSW licensure is required. Minimum of 1 year of experience in Healthcare, Medical, Community or Psychiatric setting is required. Responsibilities: + Provides medically related social services to assist patients to attain or maintain the highest physical, mental and psychosocial well-being. + Develops written treatment plan based on clinical assessments: Empowers patient to be actively involved in care planning and teaching needs of patient and family support system. Educates and encourages patient/family to utilize patient education tools and community providers/resources to prevent unnecessary hospitalizations /ED visits. Provides plan of care to include actions, plans and goals based on assessments and timeframes for outcomes. Revises treatment plan in accordance with ongoing evaluation and patient responses. Develops appropriate plan for readmissions to include appropriate post hospitalization referrals, follow up appointments as requested and documents critical interventions timely. + Provides Community/Services linkage and advocacy in accordance with the treatment plan. Advocates on patients’ behalf; based upon patients’ verbalization. + Develops and maintains knowledge of hospital and community resources. + Performs case management functions including referral and assistance with obtaining various services via information and/or linkage to community resources, medical insurance coverage - Medicaid, managed care/dual-eligible parameters; etc. + Actively assists and facilitates the discharge plan of assigned patients which may include assisted living facilities, long term care facilities in a skilled nursing facility, inpatient and outpatient substance abuse facilities, office for people with developmental disabilities (OPWDD), subacute rehab facility, homecare agency, etc… + Facilitates transfer to other healthcare facilities per state and federal regulations to ensure most appropriate level of care to conserve patient, payer and hospital resources. + Actively participates in weekly multi-disciplinary rounds regarding complex case management of patients. Collaboratively formulates post-hospital plan with patient, family, healthcare providers and/or community-based organizations, agencies (Drug/Substance Abuse, Life-Cycle Violence, Adult and Child Protective Services, Guardianship, Mental Health, HIV/Aides, OPWDD) or other healthcare facilities which is done simultaneously with assessment, treatment, intervention activities and assists in coordination of community care plan. + Actively participates and contributes to organizational committees, community organized meetings/committees and/or support groups requiring the expertise of the social worker and the population served. + Consults Medicaid Office to Initiate Medicaid Process when necessary. + Tracks inappropriate admissions and escalates cases to the Director to facilitate process improvements and/or education. + Performs and/or completes the readmissions risk assessment. + Performs New York State Screen and/or Level II Screen when necessary. + Verbally assists those who are grieving or having behavioral symptoms; and promotes the psychosocial and emotional well-being of patients and families. + Performs Case Management and/or Social Work Assessment + Performs Psychosocial Assessment as needed; and on all mental health and pediatric admissions as assigned. + Efficiently escalates barriers and/or legal case to the Director of Case Management & Social Work Services and/or delegated covering leadership. + Rotate On-Call Weekend coverage. + Mentor, train and/or support new staff.