Hiring for Clinical Social Worker , Acute Care Social Worker (Medical) – Discharge Planning in Sit

Minimum 2 years' experience in TRANSITIONAL CARE in a hospital setting.

Flu vaccine required.

FINGERPRINT CARDS ARE REQUIRED to be submitted within 1 week of offer for ICPA background clearance. 

• This position works closely with the inpatient multidisciplinary care team and provides pro-active integrated social services care management that supports the biopsychosocial needs of patients admitted to the hospital from birth to end of life. This position works directly with patients and their families in providing support, planning for discharge from the hospital, identifying barriers to discharge, assisting with financial and housing needs, working with state and federal agencies in providing information for placement needs, identifying custodial issues, referring patient in crisis to behavioral health, handles referral and consults from providers in primary care and outlying clinics within scope of responsibilities. Responsible for all swing bed admission assessments and patient disposition. This position provides supportive counseling, encouragement, coaching, and linkage with essential community services that support everyone's unique healthcare needs.
  


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  Essential Functions and Accountabilities of the Job
  Works closely with the inpatient multidisciplinary team as a member of the Care Coordination team to assess the biopsychosocial needs of any patient admitted to the hospital for medical care.
  
  
  
  
  Responsible for discharge planning working in collaboration with the Inpatient Care Coordinators to include identifying barriers to discharge, documentation, identifying community resources and agencies that may be needed at the time of discharge, identifying Durable Medical Equipment (DME) needs, developing discharge plan in agreement with patient and/or family/caregiver.
  
  
  
  
  
  Completes swing bed assessments at the time of admission into subacute rehabilitation services and ensures the patient and/or family/caregiver understand this level of care and participation requirements.
  
  
  
  
  
  Facilitates or co-facilitates patient/family care conferences to ensure the patient and family/caregiver have knowledge and understanding of acute/chronic illness, understand the plan of care, and to provide guidance in navigating the health care system.
  
  
  
  
  
  Assists patients to make decisions about their health care and whether they would like family/caregiver involved in those decisions (i.e., Advance Directive, Power of Attorney, POLST, etc.).
  
  
  
  
  
  Identifies what community resources are available to assist the patient and/or family/caregiver during hospitalization and recovery; submitting any requests that may support the patient in meeting basic living requirements (i.e., housing, meals, transportation, etc.).
  
  
  
  
  
  Assisting patients with any financial or legal matters (i.e., banks statements, referral to lawyers, applying for VA/VOICE services, applying for Medicaid, etc.)
  
  
  
  
  
  Assisting patient with long term care or assisted living needs; assisting with application process, verifying payer source, arranging for transportation and escort to facility.
  
  
  
  
  
  Finding alternative solutions to meet the physical and emotional needs of each patient.
  
  
  
  
  
  Assisting patients with dental/denture care, podiatric care, eye care, and hearing services while a paient is in the hospital.
  
  
  
  
  
  Refers to Social Service Clinician (LCSW) for chemical dependence, mental health, and crisis support intervention.
  
  
  
  
  
  Maintains complete and accurate records as required by policy and state and federal regulations.
  
  
  
  
  
  Participates in daily and weekly (Swing Bed) multidisciplinary team meetings.
  
  
  
  
  
  Participates in staff/team trainings and meetings and incorporates concepts and skills into the delivery of patient services.
  
  
  
  
  
  Participates in all required and assigned  training.
  
  
  
  
  
  Establishes and maintains up-to-date knowledge and effective working relationships with local community resources.
  
  
  
  
  
  Develops and maintains a trusting and partnering relationship with assigned patients to assist in the success of their care and recovery.
  
  
  
  
  
  Supports provider decision making and builds on provider-patient interventions.
  
  
  
  
  
  Coordinates and works well with other team members to ensure continuum of care.
  
  
  
  
  
  Obtains complete and accurate information in a courteous, respectful, and culturally sensitive manner.
  
  
  
  
  
  Documents patient notes clearly and timely to provide adequate information for other health care providers.
  
  


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  Education, Certifications, and Licenses Required
  BSW or MSW in social services required.
  
  
  
  
  BLS preferred
  
  
  
  
  
  Experience Required
  Minimum of 2 years of experience in a hospital environment in social work.
  
  
  
  
  Must be at least 21 years of age.
  
  


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  Knowledge of
  Demonstrated understanding of sound ethical practice in conjunction with the established and defined ethics of one’s training, discipline, and education/license level.
  
  
  
  
  Knowledge of basic nutrition, physical activity and tobacco cessation recommendations for physical health and disease prevention.
  
  
  
  
  
  Case management principles and application in integrated settings using tact, discretion, initiative, and independent judgment within established guidelines.
  
  
  
  
  
  The use of customer service and recovery skills.
  
  
  
  
  
  Knowledge and awareness of community support resources.
  
  


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  Skills in
  Communication skills to report patient activities and deviations from normal; ability to interact positively and effectively with patients and families.
  
  
  
  
  Use of equipment and software, such as: computers, electronic health record, fax, google drive and phone system.
  
  
  
  
  
  Application of effective and clear oral and written communication.
  
  
  
  
  
  Empathic and supportive listening.
  
  
  
  
  
  Developing interpersonal relationships to work as an effective team member.
  
  


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  Ability to
  Maintain strict confidentiality of patient care information.
  
  
  
  
  Maintain documentation in compliance.
  
  
  
  
  
  Consistently utilize professional communication and conflict resolution skills.
  
  
  
  
  
  Multi-task and work independently in a fast-paced, dynamic environment.
  
  
  
  
  
  Maintain compliance with annual competencies.
  
  
  
  
  
  Provide advocacy and outreach.
  
  
  
  
  
  Problem-solve and use conflict resolution skills to develop and maintain good working relations with other staff and departments.
  
  
  
  
  
  Meet patients’ needs in a prompt and appropriate manner.
  
  
  
  
  
  Work with individuals of all walks of life, skills, and abilities including individuals dealing with various addictions, experiencing homelessness and severe and persistent mental illness.
  
  
  
  
  
  Use the computer system to obtain and document patient information.
  
  
  
  
  
  Effectively coordinate with multi-disciplinary team and providers in accomplishing goals/objectives of treatment plan.
  
  
  
  
  
  Ability to work collaboratively with other state and community agencies on behalf of patients and/o
  
  
  
  
  
  Ability to effectively organize time, responsibilities, and accomplish tasks by established deadlines and time frames.