The Social Worker is responsible for managing the social, emotional and financial wellbeing of patients needing the services of the Clinical Social Worker. The Social Worker is responsible for developing and executing the patient discharge plan, including coordination of the services required by the patient upon discharge. They are responsible for creating an initial appropriate assessment of the patient providing any psycho-social intervention as needed. The Social Worker will complete ongoing reassessments for assigned patients throughout their hospital stay, accept referrals from the outpatient areas and refer to community agencies as necessary. The Social Worker will provide education/consultation to the Nurse Managers and Nursing Staff to ensure achievement of quality patient outcomes.
- Involves other departments in project planning and implementation.
- Supports others in the department and provides help and assistance when possible.
- Regularly attends and participates in team and/or departmental meetings and activities.
- Keeps others in the department informed of relevant information.
- Regularly offers and requests constructive feedback and coaching.
- Establishes and maintains effective working relation
Service Excellence (both internal and external)
- Welcomes patients/customers/employees in a warm, friendly manner.
- Actively listens and constructively responds to questions and concerns in a timely manner.
- Ensures that the dignity of the patient/customer/employee is maintained at all times.
- Abides by and upholds the hospital's service excellence standards.
- Respects the diversity of the patient/customer/employee population.
- Demonstrates safe and effective use of equipment.
- Collaborates with the multidisciplinary team to identify high-risk medical/social management patients.
- Develop an individualized plan with the Physician/Hospitalist for appropriate services for the patient.
- Work collaboratively with the RN Case Manager to manage clinically complex discharges
- Attends and contributes to daily rounds with the RN Case Manager to discuss assigned patients
- Coordinate discharge/follow up activities.
- Discuss with families the financial ramifications of their decisions and provide guidance in placement issues.
- Provide individualized psychotherapy, supportive counseling and group therapy as needed.
- Make referrals to community agencies when appropriate.
- Identify potential legal or risk management issues and discuss with Director/Manager.
- Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcomes.
- Identify service needs, systems issues and opportunities for expansion of services.
- Participate in continuing education programs that are relevant to job function.
- Act as a patient advocate.
- Document initial assessment, proposed plan, any changes to plan and final discharge plan in the medical record in a timely manner.
- Communicate to Skilled Nursing Facilities, Community Health Agencies, Physicians and other staff in a timely manner
- Complete statistical reports as requested by supervisory staff.
- With input from the RN Case Manager educate PCPs and clinical staffs on alternative care options including high-tech home care, skilled nursing facility capabilities, and disease management initiatives.
- Educate patients regarding managed care and Medicare processes/regulations.
- Provide patient teaching to patient and/or family.
- Promote Clinical Social Work services within legal, ethical and professional standards.
- Demonstrate effective leadership skills.
- Serve as a resource for members of the Case Management department.
- Provide education/consultation as needed to other health care team members and to health care consumers.
- Attend Utilization Management Committee meetings as assigned and scheduled.
- Participate in facility Quality Improvement Plan through unit and/or divisional quality control/quality improvement activities.
- Maintain current up to date knowledge of regulatory requirements.
- Collaborate with other agencies for the education and benefit of the staff and hospital.
- Represent the department on hospital wide teams for the betterment of service to the patients.
- Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
o Commits to recognize and respect cultural diversity for all customers (internal and external).
o Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.
Performs other duties as assigned
REQUIRED KNOWLEDGE & SKILLS:
Experience (Type & Length):
- Strong understanding of managed care
- Sound clinical judgment
- Excellent function development and management skills
- Excellent communication and negotiation skills
- Relationship manager - providers, committees, payers
- Strong organizational skills
- At least two years of case management and managed care experience.
- Two years' experience in the clinical setting. Experiences in developing and facilitating patient discharges from an acute care setting.
- Excellent assessment, diagnostic and crisis intervention skills
- Current Massachusetts license as LCSW, preferably LICSW or LICSW eligible.
- Certification in Case Management Preferred