Medical Social Work, Per Diem (2026-0418)

About the role

The Medical Social Worker or Crisis Counselor assesses, coordinates, facilitates, and negotiates services and resources to support coordination and continuity of care in the most appropriate care setting and cost-effective manner for specified populations. This includes collaboration with patients, families, physicians, nurses and other members of the health care team to address patients' medical, disposition, and psychosocial needs through effective coordination of services commensurate with available financial resources and the patient's right to self-determination across the continuum.

Responsibilities

• Review past and present medical records to determine history, admitting diagnosis or procedure, and plan of care compared to previous history and care needs;
• Gather pertinent information about the patient's psychosocial, functional and financial situation to identify needs;
• Meet with patients/caregivers to evaluate clinical, psychosocial, functional and financial status;
• Communicate with the multidisciplinary team (physicians, nurses, therapists, social workers, chaplain, etc.) as needed to complete assessment;
• Establish a discharge plan based upon individual patient needs, patient/care-giver preferences, and existing or proposed treatment options in order to support and promote desired clinical, service and financial outcomes in a timely manner;
• Provide relevant education and information regarding resources to patient/caregiver to facilitate informed decision making and active participation in the plan for transfer/discharge;
• Determine realistic goals with patient/caregiver regarding available options, empowering them to make choices in their best interest;
• Identify benefits and coordinate resources based on patient's needs and preferences;
• Work with insurance companies and/or public health benefit programs (DSHS, Medicare, Medicaid, County, State) to optimize benefits to patient;
• Initiate timely family conferences or multidisciplinary case conferences with the treatment team for complex transition discharges;
• Independently complete assessment and plan interventions sensitive to the patient's cultural, social, physical, mental and economic status and developmental state;
• Manage and prioritize work based on clinical needs, length of stay, required complexity of interventions and acuity of care;
• Document all assessments, plans, and interventions in the medical record with clarity and conciseness unique to each specific patient or family interaction and in accordance with professional, legal, regulatory and departmental standards;
• Perform self-referral screens Monday through Friday, and as appropriate on weekends, per Discharge Planning Review Process, to identify potentially high risk patients who may have an adverse health consequence without a case management order or a discharge plan;
• Communicate effectively with other members of a diverse care team using appropriate interpersonal skills, group facilitation and conflict management skills as appropriate;
• Maintain current knowledge of case management, utilization management, and discharge planning resources;
• Work collaboratively with the Utilization Management team and Patient Financial counselors;
• Refer quality, infection control and risk management issues to appropriate individual or department;
• Perform other duties as assigned, including orientation and training of new staff members;
• Serve as committee member or liaison to community partners per request of management.

Qualifications

• Ability to assess the psychological and social needs of patients in the medical setting; as well as to create, implement, and evaluate the effectiveness of care plans which address identified needs;
• Effective communication skills, including group facilitation and conflict management skills;
• Ability to work in a collaboratively team setting with peers at all times;
• Interpersonal skills necessary to interact with the interdisciplinary teams of care providers, including physicians and nursing staff, to coordinate care for patients and families;
• Sensitivity to coordination of care requirements for all patients and families from a variety of ethnic, cultural, social, and economic backgrounds and with varied medical and developmental needs;
• Knowledge of community resources and how to access them effectively and efficiently;
• Knowledge of the healthcare financial environment, reimbursement, and length of stay management;
• Ability to work independently without close supervision; set priorities, meet outcome expectations and deadlines;
• Ability to function in multiple and varied settings across the facility;
• Ability to set priorities among multiple demands; produce accurate work and meet deadlines;
• Neat and well-groomed appearance consistent with VMC dress code policy;
• Experienced navigator of basic electronic applications including: Outlook, Office, and calendar management;
• Experienced in use of electronic health record (EHR).