Social Worker - Discharge Planner

Social Worker - Discharge PlannerBecome part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.Summary: 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 membersProactively 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 neededAdheres to Patient Bill of Rights and National Association of Social Workers ' Code of Ethics.Supports secondary level of care placement issues as needed by departmentAssist patients in accessing indigent drug programsOther duties as assignedEducation Requirements: Bachelors of Social Work (BSW) required.Licensure/Certification Requirements:Professional Experience Requirements: No previous experience required.