About the role
Work Status Details : Full Time | 80.00 Hours Every Two Weeks Exempt from Overtime : Non-Exempt Shift Details : M-F Department : Care Management | Reports To: Director-Case Management & Social Work ****A $26,000.00 hire‑on bonus is available for this position. The payment schedule and distribution details will be discussed at the time of hire.**** The mission of Faith Health is to serve Christ by providing all people with exemplary medical services in an environment of love and care.
The social service worker is responsible for working in a team structure with the RN Case Manager to effect overall care coordination with the emphasis on psychosocial assessment and intervention, complex discharge planning, knowledge of community resources, appropriate documentation in the medical record and networking and collaborating with other hospital disciplines and community agencies. The social worker assists the patient, family/guardian and all members of the healthcare team in the discharge planning process.
Social worker is accountable for intervening with patients and families, by applying critical thinking skills to monitor psychosocial status and issues that impact the clinical progression and transition/discharge plan for patients including, coping and decision making. Demonstrates positive communication and interpersonal skills with patients, families and coworkers and participates in patient and family conferences as needed.
The social worker must demonstrate the knowledge and skills necessary to provide age-appropriate patient care and is accountable to the policies and procedures of the organization. Social Worker in the Care Management Department is expected to adhere to the hospital and social work codes of ethics. The listing of job duties contained in this job description is not all inclusive.
Duties may be added or subtracted at any time due to the needs of the organization.
Essential Job Duties and
Participates and implements discharge planning activities for complex patients in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers. Evaluates referrals and identifies discharge planning needs in accordance with established criteria. Collaborates with Nurse Case Managers on the initiation of the discharge plan within 48 hours of admission to address individual patient needs.
Communicates with the patient/family and healthcare team to assess and identify individual discharge needs and desires, including those specific to the age of the patient being served (neonate, child, adult, and geriatric). Assists the patient/family and healthcare team in implementing the discharge plan. Assists the patient/family in investigating eligibility and applying for Medicaid or SSI by referring to the financial counselor as appropriate.
Utilizes community resources and refers the patient/family to appropriate agencies and services when necessary. Communicates with extended care facilities to assure bed availability and arranges placement. Arranges transportation for emergent and non-emergent transfers via ambulance, air ambulance, non-emergent transport, private vehicle, etc.
Arrange home health care for complex patients including necessary equipment and personnel prior to discharge. Documents patient interviews, evaluations, recommendations and summarizes in the medical record. Revises documentation, as circumstances warrant, keeping patient information current and up to date.
Collaborates and works in partnership with the interdisciplinary treatment team in the transition/discharge planning for patients; regularly participates in team meetings and/or updates team on a regular basis. Communicated information and judgements, based on interaction with patient/family, and keeps appropriate people aware of pertinent changes or problems in a patient’s condition, as observed. Demonstrates ability to prioritize workload in accordance with patient needs and in accordance with departmental goals and objectives.
Research resources that are available to meet the social, economic, and emotional needs of the patient. Observes all established policies and procedures throughout the daily work routine. Assesses the patient’s and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.
Maintains a working knowledge of financial reimbursement methodology for all payers to identify any financial risk/ need for acute care admission as well as post-discharge placement. Maintains knowledge of community resources and keeps a referral directory with updated information of available services and contact information. Applies advanced problem-solving techniques in planning, assessing, implementing and evaluation of patient discharge needs.
Understands the Care Management/Social Services philosophy and principles of interdisciplinary team management and collaborative practice. Intervenes when variances occur in the patient’s individualized discharge plan. Assists with discharge planning needs and inappropriate admission prevention in the Emergency Department (ED) and Clinical Decision Unit (CDU).
Identifies and documents avoidable days/delays daily. Notifies financial services of unfunded patients. Ability to communicate with patients and their families regarding Important Message from Medicare (IMM), Appeal rights, Hospital Issuance of Notice of Non-coverage (HINN), Advance Beneficiary Notice (ABN), processes and deliver notifications.
Provides social services to patients in outpatient areas of Faith Health as well as Home Health and Hospice patients under the care of Faith Health Home Healthcare. Demonstrates flexibility as patient needs and census changes. Inpatient Hospice Social Service Worker
Assess patient/family social and emotional factors in order to estimate their potential to cope with terminal illness and death. Provide psychosocial counseling and support to the patient/family experiencing social, and economic conflict. Assist patient/family and staff in utilizing community resources.
Assess patient/family financial and insurance status and assist with appropriate resources as indicated. Responsible for maintenance of electronic medical records, assuring accuracy, completeness and compliance with regulations, certification standards, legal and ethical standards. Identify and address comfort care needs in collaboration with other members of the Home Health Care team.
Coordinate patient and family services. Provide psychosocial education to patients, family, and caregivers about coping skills, hospice and palliative care. Facilitating advance care planning and lifespan planning.
Mediating conflicts with families, between clients and the care team and between service organizations. Maintain the dignity of the dying patient. Support the patients and family’s unique spiritual and cultural beliefs.
Assist patient/family with end-of-life plans such as funeral arrangements or establishing an advanced director. Assess family in regard to bereavement risk and offer/provide emotional support to survivors through mailings, calls, and coffee support meetings to bereavement families for a minimum of 12 months’ post death. Refer survivors to professional assistance if note complicated/high risk grief.
Hours will be dependent on patient census and workload. Ability and willingness to work a flexible schedule, to include after-hours and weekends as necessary. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
Reasonable accommodations may be made to enable individuals with disabilities to perform the
. Other information: Job
The requirements listed below must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required.
Master's Degree required. EDUCATION FIELD OF STUDY: Social Work required.
Previous clinical experience preferred. Previous healthcare experience preferred. 2 years of previous experience in the filed preferred.
Language Skills - Ability to read, write, speak, and understand the English language required. Other Certifications/Requirements: Current, valid driver's license issued in the state of legal residence required. Operate Faith Health owned vehicles required.
Faith Health is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.