Social Worker Ambulatory Care Management

Provides social work services to individuals or groups including: screening, psychosocial assessment, discharge planning, determination of social work goals, appropriate concrete and/or therapeutic interventions and follow-up. Exercises a substantial degree of professional judgment, recognizing deviations from the usual patient/family functioning, anticipating problems and taking measures to maximize coping capabilities. Documents activity according to department and program protocols or standards. Implements interventions substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources. Advocates for patient involvement in the plan of care. Initiates and coordinates interventions with the activities of other members of the health care team. Collaborates with community agencies and institutions to plan continued care and to coordinate interventions related to finances, housing, childcare, family discord and other psychosocial problems. Provides crisis intervention services. Assists with managing utilization of hospital resources especially as related to patients with complex continuity of care needs. Supports and participates in the case management planning process to achieve desired outcomes. Provides education to patients/families regarding Advance Directives for health care decision-making. Assists with execution of these documents as appropriate. Communicates effectively with patients, family, other members of the health care team and community agencies and facilitates resolution of issues which could impact on continuity of care (e.g., prior-approvals, application requirements, transfer paperwork). Establishes and maintains effective professional relationships, positively representing the social work profession throughout the organization and in the community. Promotes constructive approach to problem solving. Adheres to the professions Code of Ethics; consistently practices within a framework guided by ethical principles. Participates in the orientation of new staff and/or education of social work students. Participates in unit-based educational programs to enhance the understanding of psychosocial aspects of health care delivery. Works cooperatively with other professional and non-professional staff to identify and resolve problems in the service delivery systems and to improve quality of patient care. Participates in the quality improvement process as it relates to supported area. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards. Major Responsibilities Provides social work services to individuals or groups including: screening, psychosocial assessment, discharge planning, determination of social work goals, appropriate concrete and/or therapeutic interventions and follow-up. Exercises a substantial degree of professional judgment, recognizing deviations from the usual patient/family functioning, anticipating problems and taking measures to maximize coping capabilities. Documents activity according to department and program protocols or standards. Implements interventions substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources. Advocates for patient involvement in the plan of care. Initiates and coordinates interventions with the activities of other members of the health care team. Collaborates with community agencies and institutions to plan continued care and to coordinate interventions related to finances, housing, childcare, family discord and other psychosocial problems. Provides crisis intervention services. Assists with managing utilization of hospital resources especially as related to patients with complex continuity of care needs. Supports and participates in the case management planning process to achieve desired outcomes. Provides education to patients/families regarding Advance Directives for health care decision-making. Assists with execution of these documents as appropriate. Communicates effectively with patients, family, other members of the health care team and community agencies and facilitates resolution of issues which could impact on continuity of care (e.g., prior-approvals, application requirements, transfer paperwork). Establishes and maintains effective professional relationships, positively representing the social work profession throughout the organization and in the community. Promotes constructive approach to problem solving. Adheres to the professions Code of Ethics; consistently practices within a framework guided by ethical principles. Participates in the orientation of new staff and/or education of social work students. Participates in unit-based educational programs to enhance the understanding of psychosocial aspects of health care delivery. Works cooperatively with other professional and non-professional staff to identify and resolve problems in the service delivery systems and to improve quality of patient care. Participates in the quality improvement process as it relates to supported area. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards. Licensure, Registration, And/or Certification Required Social Worker license issued by the state in which teammate practices. Education Required Master's Degree in Social Work. Experience Required Typically requires 1 year of experience in providing social work services in a complex health care system. Knowledge, Skills & Abilities Required Demonstrated knowledge of social work principles and methods, and the ability to apply these in a health care setting. Demonstrated decision making, team building, time management, customer service, and conflict resolution skills. Excellent communication and human relation skills. Intermediate computer skills including word processing, presentation applications and electronic mail. Certification Addendum Team members will maintain annual educational requirements for hospital based certifications (e.g.DNV, CARF or others). Physical Requirements And Working Conditions Generally exposed to a patient care environment. May be exposed to mechanical, electrical, chemical, and radiation hazards as well as blood and body fluids; therefore, personal protective equipment must be worn as necessary. Must sit, stand, speak, read/write, and walk throughout the workday. Position may require travel; therefore may be exposed to road and weather hazards. Operates all equipment necessary to perform the job. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. #J-18808-Ljbffr Advocate Health Care