Medical Social Worker

Position Summary:

The Social Worker is responsible for facilitating care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for assessing the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable read admissions. This individual will be able to cover OPD, MTU, ICU, ER, and other areas as needed.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Conduct assessments to evaluate the patient's emotional, social, and psychological needs.

• Assess the patient’s support system (family, friends) and social environment.

• Identify any factors that may impact recovery, such as financial issues, housing instability, or lack of social support.

• Provide counseling to patients and families to help them cope with illness, trauma, or end-of-life issues.

• Offer crisis intervention, especially in high-stress situations (e.g., serious diagnosis, medical emergencies).

• Support mental health by addressing feelings of anxiety, depression, or grief.

• Provide care coordination and communication with patient, family, healthcare team, and external healthcare providers.

• Help with discharge planning, ensuring patients have necessary services after leaving the hospital.

• Connect patients and families with community resources, such as financial assistance, housing, or transportation services.

• Advocate for the patient’s rights and needs within the healthcare system.

• Maintain accurate records of patient interactions, assessments, and interventions.

• Document and report progress in care plans, including emotional well-being and social needs.

• Maintain strict confidentiality.

• Perform other duties as required.

Knowledge, Abilities, Skills, and Certifications:

• Knowledge of applicable tribal, federal, state, county and local laws, regulations, including The Joint Commission Accreditation.

• Ability to speak the Diné (Navajo) language, familiarity with the Diné Way, and/or a willingness to learn about culture, language, and communities served by SMH.

• Knowledge of community resources and healthcare systems.

• Knowledge of human development, behavior patterns, marital/intimate relationships, family interaction, parent/child relationship and dynamics of family systems.

• Knowledge of case management skills, ability to coordinate with medical staff and social service paraprofessionals

• Ability to establish and maintain professional relationships with individuals of varying social and cultural backgrounds and with co-workers at all levels.

• Ability to maintain strict confidentiality.

Proficiency in operating business computers and office machines including Windows software, Microsoft Word, Excel, Access, and PowerPoint.

Physical Demands:

While performing the duties of this job, the employee regularly is required to sit, utilize arms and hands to perform clerical or clinical duties, speak to clients and staff and to hear and comprehend professional and clinical conversations. The employee is frequently required to walk for various duties. The employee must occasionally lift and/ or move up to 25 pounds.

Work Environment:

Work is generally performed in an office with moderate noise level. Extended hours are provided as needed. Participation in an on-call rotation (one week at a time) will be required as well.