Clinical Social Worker (02368)

Job Description SummaryThe Clinical Social Worker acts as a patient advocate to SSH & SSMC clients. Works in coordination with the RN Case Manager to coordinate, negotiate, procure services and resources for and manage the transitional care planning of patients to facilitate achievement of quality and cost-effective patient outcomes.Responsible to work with a multi-disciplinary patient care team to optimize care coordination, behavioral and mental health and wellness, monitor patients through admissions, ED visits and collaborate with other stakeholders to transition home/to the community post discharge. This role requires varying degrees of follow-up and follow through, including fostering, executing, and expediting efficient care coordination and assessing the needs of patients and families.Works collaboratively with the interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. Utilizes SMART GOAL formation and clear, precise documentation regarding patient outcomes and interventions. The Social Worker is on site and available 4-5 days a week as well as some holidays; no nights, weekends or on-call hours required.Job DescriptionPatient ContactDoes this position have Patient contact? YesAge of Patient(s) - (check all that apply)Adolescents 13 - 18 yrs YESChildren 1 - 12 years YESAdults 19 - 70 years YESGeriatrics 70+ years YESJOB REQUIREMENTSMinimum Education - PreferredMaster's required. Must be independently licensed. Demonstrates competency in basic computer and keyboard skills required, EPIC and Outlook preferred. Knowledge of basic medical terminology preferred.Minimum Work ExperienceRecent healthcare experience or related field preferred. Experience working with pediatric patients and families, elders and their caregivers, and/or various other community populations desirable. Social worker experience required.Required LicensesLICSW – Independently Licensed Certified Social Worker orLMHC – Must be independently licensedRequired additional Knowledge and AbilitiesExcellent communication skills required: ability to work independently and autonomously. Ability to manage time, set priorities and self-origination will be essential to success of employee. Ability to work within a multidisciplinary team and in collaboration with the RN Case Manager and supporting staff.ESSENTIAL FUNCTIONSEssential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions that the person in the job is held accountable for. Following are the essential functions of the job.1 – SSMC Referralsa - Respond to and prioritize urgent high-risk cases such asCrisis interventionsDepression Screening referralsPedi BH referralsAdult Protective Service (APS) and/or Child Protective Service (CPS) referralsGuardianship referralsb - Coordinate appropriate community and resource specific referralsFinancialEducationalCounseling/family support agenciesC - Complete and document initial psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission/one business day or within 24 hours of referral2 – CMS TEAMS a – Review work list/census to prioritize patients and identify those that meet criteria for social work interventions as needed; (attending Monday morning CMS Teams Huddle on upcoming patients)b – Review patients in settings:ED when necessarySkilled Nursing Facilities – as needed for staff consultCoordination with VNA/Home Health or Family support when patient has been discharged homec – If discharge plan initiated, verify demographics and insurance information is correctd - Coordinate with CMs in various departments to ensure continuity of care and supporte - Complete and document initial psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission/one business day or within 24 hours of referralFollow progress of patient from Pre-surgical teaching/planning through 30 day post-procedure episodeSW may be asked to be involved in discharge and or transition planning for CMS Teams patients across their episodic surgical journey4 – Interdisciplinary Roundsa - Attend and actively participate in IDRs for assigned unitsb - Report during IDRsPatient's insurancePsychosocial barriersAnticipated Plan of CarePatient/family concernsFollow-up items for SW/CMc - Identify patients that would benefit from SW intervention or supportd - Report resource limitations on post-acute care benefits or denials that could impact the discharge planninge - Document avoidable delays identified during IDRs5 – Communication and Coordinationa - Communicate with care team (Physician, Provider, Nursing Staff, Ancillary) about identified psychosocial issues or barriers that might delay or prevent timely dischargeb - Update CM counterparts/care team daily or more often if necessaryc – Collaborate with internal team and external agencies to coordinate care and timely discharge:Facilitate patient care conferences and patient/family meetingsCoordinate with APS/CPS agency personal and assist with meetingsCoordinate with legal system (guardianship/adoptiond - Ensure patient/family is updated and involved in the care plan6 - Escalationa - Escalate to Case Management leadership and/or Physician Advisor (PA)b - Escalate all high-risk cases that will require additional attention or resources in order to remove risks and barriers to a timely discharge7 – Regulatory Requirementsa - Provide when appropriate the following regulatory notifications: Medicare Outpatient Observation Notification (MOON), Important Message from Medicare (IMM), Detailed Notice of Discharge (DND), Hospital-Issued of Non-Coverage (HINN) Advance Beneficiary Notice (ABN)Technology and Learninga - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role.PHYSICAL REQUIREMENTSIndicate the appropriate physical requirements of this job in the course of a shift.Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.General Activity - Frequent Standing/Walking Required, No DrivingMotion - Infrequent Activity Required-pushing, pulling, lifting, bendingMotor Skills - Use of hands required, Use of feet requiredWeight/Force - Light lifting required (Body Fluid Exposure - Yes