CSW (Certified Social Worker)

Social Worker/Discharge Planner

Become part of an inclusive organization with over 40000 teammates whose mission is to improve the health and well-being of the unique communities we serve.

The Social Worker/Discharge Planner plans organizes and directs the clinical case management functions of assigned patient population. This includes completing clinical and psychosocial assessments and facilitating timely effective and safe discharges. Collaborates with the multidisciplinary care team to identify patients at risk for readmissions and implements plans of care to reduce risk.

Responsibilities:

• Completes psychosocial screenings assessments and appropriate interventions in collaboration with patients/families physicians and other healthcare team members to meet care plan needs.
• Collaborates with Case Manager to formulate and implement discharge plans for patients with identified discharge needs.
• Accesses internal and external resources to meet patients and families discharge needs.
• Maintains working knowledge of internal and external resources as well as financial state and regulatory agency policies and requirements.
• Actively promotes coordinates and facilitates communication between patients and/or families and members of the healthcare team and/or members of the legal educational and religious communities as needed.
• Addresses complex psychosocial issues or behaviors which create or contribute to non-compliance over-utilization or resources and/or readmissions.
• Effectively identifies and resolves issues associated with competency guardianship and adoption processes. Serves as an advocate for patients physical and emotional well-being.
• Identifies possible or actual patient/family crises providing crisis intervention and emotional support and creating and facilitating effective plans for resolution.
• Identifies real/potential ethical issues educates healthcare team members and participates in resolution in collaboration with other healthcare team members.
• Proactively initiates end of life discussions with patients families and/or physicians when appropriate. Assists patients with completion of Advance Directives and Out of Facility Do Not Resuscitate Orders as needed.
• Adheres to Patient Bill of Rights and National Association of Social Workers Code of Ethics.
• Supports secondary level of care placement issues as needed by department.
• Assist patients in accessing indigent drug programs.
• Other duties as assigned.

Education Requirements: Bachelors of Social Work (BSW) required.

Licensure/Certification Requirements:

Professional Experience Requirements: No previous experience required.

Job Details