Job Description Summary
The Licensed Clinical Social Worker acts as a patient advocate and social worker to SSMC clients. Works in coordination with the RN Case Manager to coordinate, negotiate, procure services, and resources for and manage the transitional care planning of patients to facilitate achievement of quality and cost-efficient patient outcomes.
Works collaboratively with the interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care.
Key Responsibilities :
- Review work list / census to prioritize patients and identify those that meet criteria for social work interventions
- Review referrals received via Physician, Nursing or ancillary staff, Patient and family
- Initiate referrals from Case Manager (CM) or self-referral when appropriate
- If discharge plan initiated, verify demographics and insurance information is correct
- Coordinate with CM using the high-risk criteria to determine plan for completion of initial discharge planning assessment on all patients
- Complete and document initial discharge planning or psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission / one business day or within 24 hours of referral
- Begin discharge planning discussions with patient / family
Urgent Referrals :
Respond to and prioritize urgent high-risk cases such as crisis interventionsAdult Protective Service (APS) and / or Child Protective Service (CPS) referralsGuardianship referralsDischarge / Transition Planning :
Initial assessment / screening and evaluation of patient and familiesReassess the post-discharge plan to determine if additional resources are needed.Identify required authorization for post-acute services and refer to the appropriate post-acute providerAfter initial assessment complete, post-acute arrangements can be made as soon as possibleOutpatient Services :
Ensure that patient has received all information related to choice of follow-up care facilities, and / or public or private care providers, including explaining all elements of discharge, continuum of care needs and available options to patients, families and / or caregivers and documentWorking with patients and families understand the illness : treatment options as well as consequences of various treatments or treatment refusalAssist patients / families with adjusting to; possible role changes; changes in social determinants and necessity of support servicesDocument response by providersSupport patient and caregiver per provider or patient / caregiver request. An example of this may be serious illness conversations and goal of care. Arranging for resources / funds to access social care needsInterdisciplinary Rounds :
Attend and actively participate in any SSMC clinical huddles as neededReport during IDRsPsychosocial barriers to managing carePatient / family concernsFollow-up items for SW / CMIdentify patients that would benefit from SW intervention or supportCommunication and Coordination :
Communicate with care team (Physician, Provider, Nursing Staff, Ancillary) about identified psychosocial issues or barriers that might delay or prevent access to careUpdate CM counterparts / care team daily or more often if necessaryCollaborate with internal team and external agencies to coordinate careFacilitate patient care conferences and patient / family meetingsCoordinate with APS / CPS agency personal and assist with meetingsEskalation :
Escalate to Case Management leadership and / or Physician Advisor (PA)
Escalate all high-risk cases that will require additional attention or resources in order to remove risks and barriers to care
Technology and Learning :
Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organizationEmbraces technological advances that allow us to communicate information effectively and efficiently based on roleRequirements :
Minimum Education : BS in Social Work, Master's prepared LCSW or LICSW preferred. Demonstrates competency in basic computer and keyboard skills required, EPIC and Outlook preferred. Knowledge of basic medical terminology preferred
Minimum Work Experience :
Recent healthcare experience or related field preferredExperience within an admission and / or discharge function desirable, especially in high-stress areaExperience working with patients and families, elders and their caregivers, and / or various other community populations desirableSocial Worker experience desirablePreferred Licenses / Registrations : LCSW or LICSW - Licensed Certified Social Worker OR Licensed Independent Clinical Social Worker
Required Skills, Knowledge, and Abilities :
Excellent communication skills required : ability to work independently and under very stressful situations requiredAbility to time manage, set priorities and self-origination will be essential to success of employeeAbility to work within a multidisciplinary team and in collaboration with the RN Case Manager
