Department:
Scotland Memorial Hospital - Transition and Navigation Services
Status:
Full time
Shift:
1st (United States of America)
Schedule Details/Additional Information:
Experience
OMinimum Requirements: At Least 1 Year Professional Experience In Hospital Or Health Related Setting Preferred.
OExpertise With Data Management Tools. Adherence To National Association Of Social Workers Code Of Ethics.
Job Description:
1.Interviews patient/patient's social support system if applicable to complete initiate psychosocial evaluation /
assessment.
2.Provides counseling/support/education to patient/patient's social support system. Assists patients/patient's social
support system in healthy coping strategies and improving overall well-being.
3. Works collaboratively with the patients and primary care provider to establish and implement a plan of care that
meets the patient's identified psychosocial needs.
4.Works with each primary care provider to enhance the health of the patient referred, documents patient visits per
standard as well as appointment attendance and follow up. Works to close appropriate care gaps to advance
wellness.
5. Serves as a resource to SPN regarding emotional, social, and psychosocial components of the patient's illness and
its effects. Assists and facilitates a care team approach with Primary Care referring provider in understanding and
integrating aspects into the plan of care.
6.Intervenes in crisis situations, appropriately and effectively applying crisis intervention and skills
7.Works with the SPN team to assess and evaluate the patient/patient's social support system for the appropriate
level of care or environment setting to meet care needs.
8. Participates in care planning meetings as requested.
9. Maintains current knowledge and researches availability of community agencies and community resources for
social, emotional or financial assistance.
10. Rounds with each provider daily in clinic to build referral relationships and professional “warm” patient handoffs,
ensure clinic manager and providers are aware of availability daily and hours on site for acute intervention if
needed.
11. Provides information, education to patients and their social support on community resources and options
appropriate to the age of the patients served, in collaboration with the Clinical Care Team. Make referrals to
community agencies as needed.
12.Reports suspected cases of child & adult abuse/neglect/exploitation. Serves as liaison between practice,
patients/patient's social support system and Department of Social Services during evaluation/investigation.
13.Identifies and records clinical, psychosocial and financial barriers to a smooth transition across the healthcare
continuum and assists in identifying and facilitating system improvements.
14. Works with SPN leadership to identify problems, recommended solutions and works toward resolution.
15. Develops and maintains accurate clinical records in EPIC of each referred patient. Documents in EPIC according to
departmental standards.
16.Works collaboratively with SPN leadership to build LCSW integrated primary care program.
Careers
At Scotland Health Care System, we’re proud to employ a team of dedicated professionals who embody the Scotland Way.
Founded in 1946, Scotland Health Care System is a community-owned, not-for-profit organization serving Laurinburg, North Carolina. Our mission is simple yet powerful: to deliver safe, high-quality, compassionate, and sustainable health care to everyone in need.
We offer a full spectrum of services—including inpatient, outpatient, and emergency care—along with specialized programs in cancer treatment, cardiac care, surgical services, and women’s health.
Our culture is built on caring—for our patients and for our people. We believe that when we take exceptional care of our employees, they can provide exceptional care to our communities. That’s why we offer:
Competitive compensation
Family-friendly benefits including Paid Parental Leave and On-Site Childcare
Flexible scheduling
Exclusive savings programs
Career growth and advancement opportunities
If you’re looking for more than just a job—if you want a meaningful career where you can make a difference—Scotland Health Care System is the place for you. Join our team today!