Clinical Social Worker 2, PRN

University of Maryland Upper Chesapeake Health (UM UCH) offers residents of northeastern Maryland an unparalleled combination of clinical expertise, leading‑edge technology, and an exceptional patient experience. As a community‑based, integrated, non‑profit health system, our vision is to become the preferred, integrated health system creating the healthiest community in Maryland. We are dedicated to maintaining and improving the health of the people in our community through an integrated health delivery system that provides high quality care to all. Job Description Screen patients to identify needs and prioritize caseload to identify high‑risk and rising‑risk patients. Coordinate with interdisciplinary team to develop, revise, and implement appropriate discharge interventions to ensure safety and care coordination. Accept responsibility for patients’ Transitions of Care, coordinating provisions for discharge and follow‑up appointments, home health, community services, transportation, etc., to maintain continuity of care for identified high‑risk patients. Communicate with the CRM manager any pertinent findings causing a delay in care coordination, safe discharge planning, and/or LOS. Complete a thorough assessment with patient’s history including medical, physical, social, emotional, psychological, and financial needs that will assist the care team in developing a care plan. Identify barriers to health care both in social and medical need that focus on the prevention of readmissions. Promote patient self‑management, educating patients on disease, medication, access to care, self‑care support, to improve clinical outcomes and increase self‑efficacy. Provide and review the appropriate community resources/services with the patient/family. Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection. Actively participate in rounds to ensure continuity of care is communicated with other disciplines and to ensure a reduction in LOS. Have knowledge of patient plan of care. Document appropriately. Report patterns of noncompliance. Consult regularly with the inpatient provider, PCP, Director and Supervisor, and other team members to ensure that the transition plan remains relevant, appropriate, and responsive to changing patient status and/or goals. Establish an effective and appropriate means of communicating and collaborating with physicians, team members, payers and administrators to ensure safe and efficient services. Identify need for, arrange, and facilitate peer consultation/health team meeting/family conference when necessary to advance coordination of complex services/resources and medical and/or social issues. Develop and maintain collaborative relationships with the post‑acute representatives to ensure safe and confidential and transfer is timely. Participate in identifying and achieving the department’s PI initiatives and goals. Report and document process and safety issues in the Events Tracking system. Orient new team members and students. Maintain professional development best practices and continuing education for care coordination. Assist with special projects and other duties as assigned. Qualifications Master’s degree in Social Work accredited by Council on Social Work Education (CSWE). LCSW‑C (Licensed Certified Social Worker‑Clinical) licensure from the Maryland Board of Social Work Examiners. Minimum three (3) years of post‑Master’s experience is required. Compensation Pay Range: ($33.36 - $46.70) Additional Information All your information will be kept confidential according to EEO guidelines. #J-18808-Ljbffr