Social Worker - CW Care Management - Children's and Women's Hospital

Responsibilities

• Performs initial discharge planning assessments in a timely manner from time of patient admission, evaluating baseline function versus anticipated discharge needs.
• Follows Mandatory Reporting guidelines for abuse, neglect, exploitation & collaborates with associated agencies.
• Collaborates & communicates with physicians, bedside nurses, utilization management staff, therapy services, and associated clinical professionals to facilitate effective transitions to the next level of care.
• Participates in interdisciplinary patient care rounds and conferences; communicates discharge plans as part of rounds.
• Establishes and supports patient-centered and provider goals to determine next steps for a positive patient experience and well-coordinated transition of care.
• Reassesses discharge needs based on changes in patient condition or plan of care and discusses updates with patients and families/caregivers.
• Provides the patient and family resources based upon his/ her insurance options and helps them to formulate an individual discharge plan based upon their needs.
• Provides individualized discharge planning by:
  • Acting as a resource for patient/family
  • Aiding with medication access
  • Arranging transportation
  • Coordinating durable medical equipment (DME)
  • Facilitating home health services
  • Arranging hospice care
  • Coordinating rehabilitation, skilled nursing, long-term care placement, and facility transfers
  • Assisting with Veteran’s Administration and discharge needs
  • Referring to mental health facilities
  • Serving as a mandated reporter and ensuring compliance with all applicable child welfare, adult protective services, and vulnerable population reporting laws
  • Supporting probate and commitment processes as appropriate
  • Sends referrals to appropriate post-acute agencies to support safe discharge and continuity of care.
• Evaluates social determinants of health and identifies differences between initial assessment findings and discharge needs. Provides resources and referrals to address identified barriers and reduce the risk of readmission.
• Performs timely readmission assessments when applicable; initiates referrals and services aimed at preventing future readmissions.
• Collaborates with outside agencies and community case management programs to develop individualized plans of care.
• Documents all assessments, discharge plans, referrals, interventions, and actions performed in the medical record according to department policy.
• Documents avoidable delays to support leadership in identifying performance improvement opportunities.
• Abides by and enforces all compliance requirements and hospital policies, including confidentiality, while performing duties ethically and in alignment with organizational values.
• Performs timely intervention related to discharge planning assessment and consults placed for patients as identified by a healthcare team member having urgent social or discharge planning needs.
• Enhances professional growth and development through participation in educational programs.
• Participates in committees and performance improvement activities, or other quality initiatives as assigned.
• Maintains professional practice in accordance with the National Association of Social Workers (NASW) Code of Ethics, hospital policies, applicable laws and regulations, and standards of professional conduct.
• Screens for indicators of abuse, neglect, domestic violence, human trafficking, and exploitation during discharge planning assessments. Provides immediate intervention when safety concerns are identified, prioritizing patient protection and stabilization.
• Serves as a mandated reporter and ensures compliance with all applicable child welfare, adult protective services, and vulnerable population reporting laws.
• Coordinates with physicians, nursing, care management, security, legal counsel, and risk management to support investigation, reporting, and care planning.
• Edicates patients and families on available protective resources and support services when appropriate.
• Maintains strict confidentiality and professional documentation standards related to sensitive reporting and investigations.
• Demonstrates the ability to provide competent patient care to implement an effective discharge plan to the following patient populations: neonate, pediatric, adolescent, adult, and geriatrics.

Qualifications

• Master's Degree in social work from an accredited institution
• OR Bachelor's Degree in social work from an accredited institution and 2 years of social work experience
• OR Bachelor's Degree in a related field from an accredited institution and 3 years of social work experience
• Licensure with the State of Alabama as a Social Worker