Social Worker

Major Responsibilities

• Provides social work services to patients, families, and individuals including psychosocial assessment, screening, determination of needs evaluation, appropriate interventions and follow up, and discharge planning.
• Implements interventions substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources and payer network.
• Participates as part of the multi-disciplinary health care team to develop safe and timely coordination of care including but not limited to post-acute placement, palliative/hospice service lines, medical equipment, home healthcare, outpatient follow up, mental health resources, and other community resources.
• Advocates for patient involvement in the plan of care. Initiates and coordinates interventions with the activities of other members of the health care team.
• Maintains up-to-date knowledge of community resources, legislation, and regulations impacting health care delivery and educating patients and families on these issues as appropriate.
• Provides resources to patients and families to ensure a timely discharge and to provide an appropriate link with post-acute care providers and services.
• Provides support and connection to additional services such as bereavement and loss, ethical issues, advanced directives, and end of life issues.
• Connects patients to appropriate agencies on issues of suspected abuse and neglect, domestic violence, guardianship, and other social matters.
• Collaborates with community agencies and institutions to plan continued care and to coordinate interventions.
• Provides resources and education to patients and families regarding appropriate resources and access to community social services.
• Communicates effectively with patients, family, other members of the health care team and community agencies and facilitates resolution of issues which could impact on continuity of care (e.g., prior-approvals, application requirements, transfer paperwork).
• Documents activity according to department and program protocols or standards.
• Manages the progression of patients stay with the goal of optimizing the LOS and ensuring appropriateness of assigned Level of Care.
• Manages the patient's care across the continuum to decrease unnecessary readmissions.
• Manages and coordinates patient care within an ACO environment to help facilitate patient outcomes through in network care coordination.
• Accountable for site specific KRA goal achievement as it relates to Care Coordination across the continuum.
• Participates in the orientation of new staff and/or education of social work students.
• Provides education to patients/families regarding Advance Directives for health care decision-making. Assists with execution of these documents as appropriate.
• Participates in legal proceedings as necessary to secure legal decision-makers.
• Maintains professional standards and responsibilities for his/her own professional practice according to accreditation, hospital, system, state and NASW Standards and Code of Ethics.
• Completes all required continuing education to maintain licensure and increase knowledge within area of practice specialty.

Minimum Education and Experience Required

• License/Certification: IL-LSW Eligible, LCSW preferred issued by the State of Illinois / WI-Social Work Certification issued by the State of Wisconsin
• Level of Education: Master's degree in social work from a Council on Social Work Education (CSWE) accredited school
• Years of Experience: 1 year of social work experience in healthcare

Minimum Knowledge, Skills, and Abilities

• Demonstrated knowledge of social work principals and methods and the ability to apply these in a health care setting.
• Demonstrates time management, professional accountability, and documentation skills.
• Demonstrates communication skills and the ability to collaborate within a multi-disciplinary team.
• Demonstrates and acts in accordance with safety principals of an accountable care organization.

Physical Requirements and Working Conditions

• This position requires travel, therefore, will be exposed to weather and road conditions.
• Operates all equipment necessary to perform the job.
• Exposed to a normal office environment.
• Exposed to patient care environment. May be exposed to hazardous materials and life-threatening diseases, therefore team members must abide by personal protective equipment as ordered.
• Weekend, holiday, and evening coverage per site requirement.
• Position requires sitting, standing, speaking, reading/writing, and walking throughout the workday.
• Fast paced work environment with established time constraints per site.

This response is AI-generated, for reference only.