Social Worker (MSW) Population Health-OB

Role Overview Provides social work services, assesses and enhances the patient’s, family’s or significant other’s ability to cope with physical, emotional, and environmental problems related to illness, convalescence, and discharge planning. Works collaboratively with the multidisciplinary healthcare team to establish a discharge plan for the patient. Responsibilities Interact with co‑workers, visitors, and other staff consistent with Jefferson values. Conduct psychosocial assessment and reassignment of patients and significant others. Develop and implement a plan of intervention addressing identified needs. Collaborate with the multidisciplinary team to ensure appropriate discharge planning. Provide counseling for patients, families, and significant others to assist with coping with new diagnoses, chronic illness, and palliative or terminal care. Advocate on behalf of patients and families to obtain necessary services. Serve as a resource and provide counseling and intervention related to treatment decisions and end‑of‑life care issues. Refer patients and significant others to community‑based services to meet continuum of care needs. Coordinate team and/or family conferences when necessary to facilitate care progression. Provide psychosocial counseling and crisis interventions to patients and significant others. Intervene in cases of child abuse/neglect, domestic and elder abuse, guardianship, foster care, adoption, psychiatric assessment and placement, advance directives, trauma, and substance abuse. Facilitate completion of placement‑related documentation for nursing home grants, applications, etc. Complete referrals to options programs where appropriate. Document in accordance with hospital and departmental requirements. Work with case managers to provide discharge planning services per policies and procedures. Identify patients and locate family or next of kin. Educate patients and significant others on the process for obtaining health insurance. Provide appropriate documents to apply for welfare insurance and initiate medical assistance applications when necessary. Follow up with external services regarding applications. Provide psychosocial assessment and intervention throughout hospitalization and discharge planning, updating electronic medical records. Supervise field placement of MSW students. Refer case to the Placement Official Social Worker as needed for discharge placement. Precept and mentor new staff members. Facilitate and coordinate discharge plans for weekend discharges, including home care/hospice services, transportation, and post‑acute facility placements. Assess and develop interventions for trauma patients. Obtain relevant post‑acute authorizations. Manage Livanta appeal determinations and address alternate discharge plans if necessary. Provide updates to post‑acute facility liaisons regarding possible weekend discharges. Review discharge orders to determine which patients can transition to the next level of care. Assist with completing relevant 302 paperwork. Document updates for weekday staff per department procedures. Qualifications Master’s Degree from an accredited Masters of Social Work program required. Two years of hospital‑based social work experience. Knowledge of medical terminology, disease processes, community resources, and insurance regulations and requirements. Skill in working with multidisciplinary teams, outside resources, patients, and families. Ability to establish an appropriate plan to safely discharge patients to the next level of care. Additional Qualifications and Physical Demands Lift and carry 25 lbs. frequently; sit and stand frequently; use keyboard often. Patient care providers may need to kneel, bend, squat, and perform CPR. Benefits Medical (including prescription) insurance. Dental and vision insurance. Life and accidental death & dismemberment (AD&D) insurance. Short‑term and long‑term disability. Flexible spending accounts. Retirement plans. Tuition assistance. Voluntary benefits providing group rates on insurance and discounts. Equal Employment Opportunity Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. #J-18808-Ljbffr Thomas Jefferson University