Social Worker (MSW) - Transitions of Care/PRN (Scheduled As Needed)
Core
Case manager promoting optimal social/emotional functioning and enabling wellness patients to utilize healthcare services for optimal health.
Role type
Transitions of Care Case Manager (Social Worker)
Builds
Post-acute care transitions, discharge plans, and care coordination for complex medical and behavioral health patients.
Domain
Healthcare / Social Work / Behavioral Health
Deliverable
client delivery
Required skills
discharge planning, resource brokering, crisis intervention, psychosocial assessment, patient advocacy, interdisciplinary collaboration, abuse assessment, Medicare notification, advance directives, financial assistance navigation, social determinants of health assessment, legal documentation for emergency detentions
Preferred skills
behavioral health experience, hospital social service experience, health care educational emphasis
Technologies
None stated
Responsibilities
Discharge screening, evaluation, and implementation of discharge plans for patients with complex needs; Reassessment of discharge plans and monitoring for changes in patient condition; Patient advocacy with support persons and healthcare teams; Interventions and support for family stress and emotional needs related to healthcare decisions; Crisis intervention and adjustment to illness or bereavement; Resource brokering for SNF, home care, hospice, infusion, LTAC, and DME; System integration and continuity of care through interdisciplinary collaboration; Follow-up calls to assess patient care needs and apply interventions per Transitions of Care Discharge Policy; Provision of resources to facilitate effective discharge plans; Chemical dependency and mental health assessments with referrals to treatment; Readmission assessments and trending; Provision of Medicare Notification Letters; Assistance with resolutions of financial concerns by linking to eligible programs; Abuse assessments (adult, child, sexual, domestic violence) and referrals; Assessment of Social Determinants of Health and assistance accessing government programs and social services; Provision of information and execution of advance directives; Psychiatric consultation to Emergency Rooms and Medical/Surgical Units; Serving as point person for cases involving child/elder abuse, domestic violence, and protective issues; Interpretation and communication of complex patient and family needs; Support of complex discharge planning and coordination of care transitions; Collaboration with healthcare team members to facilitate safe, timely, and effective care and discharge planning; Performing duties in various settings including Emergency Department, inpatient, CBC, ICU, and outpatient areas; Travel between facilities as required
Seniority
Individual Contributor, Clinical Support
