Clinical Care Social Worker
Core
Plans and coordinates patient care across the continuum, performing psychosocial assessments, crisis intervention, and discharge planning for patients with complex needs.
Role type
Clinical Care Social Worker
Builds
Transition and discharge plans of care for patients
Domain
Healthcare / Social Work
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Psychosocial assessment, crisis intervention, discharge planning, resource management, eligibility determination for social programs, collaboration with multidisciplinary teams, knowledge of federal/state/local assistance programs, documentation, care coordination
Preferred skills
1-3 years of experience
Technologies
Electronic record systems, quality screens
Responsibilities
Manage transition/discharge planning for assigned patients; Collaborate with multidisciplinary teams to facilitate patient transitions; Monitor patient progress and intervene as necessary; Maintain knowledge of community resources and assistance programs; Provide social work assessments for complex crises including mental health, substance abuse, and grief; Facilitate referrals to post-acute services; Communicate discharge plans to teams, patients, and families; Document interactions and planning activities; Assist patients with medical power of attorney and advanced directives; Utilize clinical skills for abuse, neglect, and domestic violence situations; Coordinate financial management and entitlement programs; Communicate with payors for reimbursement certification; Provide education to staff and physicians on payer regulations; Foster integration of staff and students into the healthcare team.
Seniority
Entry to Mid-level, hands-on IC
