Social Worker 2, Transition of Care

About the role

The Department of Social Work at SUNY Downstate Health Sciences University is seeking a full-time Transition of Care Social Worker 2.

Responsibilities

• Provide both inpatient and outpatient coverage, transition of care and post-acute follow up and will address patients post-discharge related issues.
• Cover for Transplant service to ensure adequate coverage at all times.
• Provide coverage in the outpatient transplant clinic can inpatient transplant unit.
• Be an integral part of the hospital multidisciplinary team, and work with patients and their families and caregivers, to assess patient and family psychosocial and discharge planning needs relevant to medical treatment.
• Provide crisis intervention, emotional support, resource information, discharge planning and legal reporting.
• Assess, plan and support patients to cope with social, emotional, economic and environmental problems.
• Help patients maintain their independence in the community.
• Work jointly with healthcare providers on social issues that may affect patients health and well-being.
• Screen and assess the psychosocial needs of the patient and family to develop, communicate, and implement an effective and comprehensive plan for psychosocial interventions.
• Provide social work services to specialty areas within the hospital that require and MS for regulatory requirements.
• Participate in daily multidisciplinary huddles in the unit assigned to discuss plan of care and discharge planning needs.
• Proactively collaborate with the interdisciplinary team to develop and carry out appropriate discharge plans.
• Coordinate transition of are needs as homecare services, DME, and placements for nursing home, acute and sub-acute rehab facilities in a timely manner.
• In coordination with Care Management Assistants, process placement of patients in SNF, sub-acute and nursing homes through discharge and closing the case within 24-hours post-discharge.
• Provide grief and bereavement counseling to patients, families and caregivers.
• Initiate and oversee guardianship referrals in collaboration with the Risk Management Department.
• Perform legal reports for suspected child abuse and elder abuse, and domestic violence referrals.
• Serve as the liaison to Administration of Children Services and Adult protective Services.
• Provide patient/family conferences and education as needed, to ensure appropriate length of stay and transition care from the hospital.
• Perform other multiple tasks, responsibilities and obligations as it pertains to the position, as the job duties are not limited to the aforementioned description.

Required Qualifications

• Master's Degree in Social Science.
• New York State Social Work Licensure (LCSW and/or LMSW).
• 1+ year of social work experience.
• Knowledge of Federal, State, and TJC regulations.
• Knowledge of Medicare, Medicaid and Managed Care Standards, requirements, benefits and benefits administration.
• Knowledge of state and federal programs that provide financial assistance to underserved populations.
• Knowledge of community resources.
• Proficiency in use of PC, Microsoft Office Suite, and clinical applications.
• Ability to work with diverse patient populations, with knowledge and sensitivity to cultural and spiritual influences impacting on patient care.
• Social work assessment and counseling skills, to include grief and bereavement counseling, alcohol, and drug intervention, and support for victims of abuse, neglect and violence.
• Possess a positive attitude, motivation and good interpersonal skills.
• Excellent verbal and written communication skills.
• Good problem resolution skill set.
• Ability to work in a multidisciplinary team approach.
• Ability to work independently with minimal supervision.
• Or, a satisfactory equivalent combination of experience, education and training.

Preferred Qualifications

• Hospital and care management experience and CCM preferred.

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