Social Worker MSW

Hospital Social Worker (MSW)

The Hospital Social Worker (MSW) provides comprehensive psychosocial support and services to patients and their families in a hospital setting. This role involves assessing patients’ social, emotional, and environmental needs, and developing and implementing care plans to address these needs. The Social Worker collaborates with healthcare providers, patients, and families to ensure continuity of care and facilitates access to community resources. This is a patient facing role with a strong focus on patient experience.

Essential duties and responsibilities include:

• Patient Assessment and Care Planning; conducts comprehensive psychosocial assessments to identify patients’ needs, strengths, and challenges.
• Develops individualized care plans in collaboration with the healthcare team, focusing on addressing social, emotional, and environmental factors affecting patient care.
• Provides emotional support, counseling, and crisis intervention to patients and their families assisting patients and their families with coping with illness, trauma, hospitalization, and post-discharge needs.
• Assists patients and families in coping with illness, trauma, hospitalization, and post-discharge needs.
• Coordinates with healthcare providers, including RN Case Managers, physicians, nurses, therapists, and other social workers, to ensure holistic patient care.
• Facilitates referrals to community resources, social services, and other support systems.
• Ensures seamless transitions between levels of care, such as from hospital to home or long-term care facilities.
• Collaborates with the healthcare team to develop and implement safe and effective discharge plans.
• Educates patients and families about post-discharge care, available resources, and follow-up care plans.
• Coordinates post-discharge services, such as home health care, rehabilitation, and transportation.
• Advocates for patients’ rights and access to necessary services and resources.
• Assists patients and families in navigating the healthcare system and accessing financial assistance, insurance, and community resources.
• Maintains accurate and up-to-date documentation in EPIC of patient assessments, care plans, interventions, and outcomes.
• Responsible for addressing the impact of social determinants of health and connecting patients and their families with resources to support them in overcoming social and economic barriers to health.
• Develops strategies to address and mitigate the effects of social determinants of health on patient care.
• Serves as a patient advocate ensuring needs and preferences are addressed and respected.
• Identifies and removes barriers to progression of care, offering resources for barriers to health care including financial, social, and logistical issues.
• Requires advanced knowledge of Medicare, Medicaid, and commercial payor guidelines.
• Participates in multidisciplinary rounds and provides input on patient's discharge plan.
• Assures that financial counselors meet with self-pay patients to determine existence of third-party payer source or assist with development of self-pay strategies.
• Assists with guardianship, unfunded and undocumented patients. Addresses and educates patients/families on Advanced Directives.

Education, experience, and qualifications:

• Master of Social Work (MSW) degree from an accredited institution required.
• Current licensure as a Clinical Social Worker (LCSW) preferred.
• Social work experience, preferably in a hospital or healthcare setting preferred.
• Experience in crisis intervention, discharge planning, and care coordination is highly desirable.