Clinical Social Worker | Care Coordination | PRN

Overview
The Clinical Social Worker provides and coordinates psychosocial and behavioral services for assigned group of patients. The Clinical Social Worker assesses, plans, implements and monitors a plan of care for assigned group of patients. This is in done in collaboration with other members of the medical team, i.e., physicians, nurses, case managers, PT/OT staff and pharmacists. Works with the care team in a designated setting to identify and, when possible, advocates for the patient. Works to provide direct services, resources and counseling that a patient/client needs to create a safe, effective and efficient transition/discharge from the hospital or clinic. Provides expertise in a crisis intervention situation and assesses for potential abuse/neglect of vulnerable patients.
Responsibilities
Identifies appropriate discharge social work needs for assigned patients (providing resources, community support, ensuring advance directives/next of kin is identified).
Partners with community agencies to coordinate care across the continuum to offer options, tools, and resources to allow patients the opportunity to achieve the desired goals.
Assists with patient evaluation and treatment to further their understanding of significant social and emotional factors underlying a patient's health problem(s).
Acts as a patient advocate: investigates and reports adverse occurrences and performs staff education related to resource deployment, discharge planning and psychosocial aspects of healthcare delivery.
Assists care team and family with end of life conversations, offers grief counseling, and performs hospice consults
Assist with determination when care conference is appropriate; coordinates scheduling with team & caregivers
Plan and support patients in coping with emotional, economic, social, and environmental challenges.
Assess for the need/eligibility for financial assessment and refer to the appropriate programs.
Performs discharge planning activities, including referrals to Home Health, Skilled Nursing, Inpatient Rehab, DME, etc. for assigned patients.
Documents patient data, plan, interventions and outcomes according to department guidelines.
Qualifications
Master's Degree in Social Work or a related field is required.
1 year of recent clinical experience applicable to the designated population served is required.