Job Requirements
The Complex Social Worker, Master’s of Social Work (MSW) oversees the discharge processes for hospitalized patients identified as having complex personal, social, financial or support barriers to timely discharge. The Complex Social Worker, MSW is accountable for the coordination of care from hospital admission to post-hospital care, expediting discharges for patients with traditionally long lengths of stay. PRIMARY ACCOUNTABILITIES Develops and coordinates, in collaboration with the healthcare team, an individualized discharge plan with appropriate post-acute care services for select patients with complex needs who are referred to or identified by the Complex Discharge Manager.
These may include: Uninsured, Lack of needed surrogate decision-maker, Homelessness, Significant financial barriers to care, or Lack of needed family and social support. Interviews patients identified as needing case management assistance, and family or caregiver to assess the patient’s health status, functional status, mental status, personal and community support systems, financial resources and environmental conditions.
Creates a discharge plan, in collaboration with the patient and family / caregivers, that is clinically appropriate, focused on the patient’s care needs, goals and preferences, and consistent with available resources and patient choice. Identifies, communicates and develops creative mutually agreeable alternatives to resolve problems, specific barriers to discharge or that impede provision of high-quality cost-effective care delivery Monitors progress toward goals and discharge readiness; revises plan in response to changes in patient’s needs and support system; recognizes potential delays and barriers to discharge and proactively works to minimize them and communicates the discharge plan to the healthcare team through a variety of means (e.g., daily rounding, interdisciplinary rounds, documentation in the medical record).
Assists the patient and family / caregiver in the selection of post-discharge service providers utilizing quality and performance data readily available; initiates referrals to resources necessary to meet patient’s goals and needs post-discharge (e.g., home care services, home health, DME, home infusion, hospice, skilled nursing facilities, long-term care facilities, assisted living, etc.). Serves in the role of local expert on the processes for guardianship, advising healthcare team on these complex cases.
Collaborates with families, APS and legal team as needed to expedite the process of establishing a needed surrogate decision -maker. Collaborates in and facilitates care planning unit conferences and patient/family team meetings for complex cases; participates in meetings, as needed, to discuss patient’s plan of care and potential discharge barriers/concerns. Partners with physicians to facilitate timely resolution of situations such as patient concerns or need for referrals to expedite the discharge plan Participates actively in unit discharge planning rounds with physicians and members of the healthcare team to effectively coordinate care and evaluate patient’s progression toward readiness for discharge Adheres to departmental and organizational goals, objectives, standards of practice, policies and procedures, regulatory and accreditation standards.
Work Experience
Master’s degree in Social Work (MSW). Work
Three (3) years’ experience in medical social work within the last five (5) years.
None Certification: American Heart Association Basic Life Support (AHA BLS) Healthcare Provider Completion Card Prior to start date and maintained. Skills/Knowledge/Abilities: Ability to think critically and analytically with little or no supervision. Ability to work independently with a minimum of direction, anticipate and organize workflow, prioritize and follow through on responsibilities.
Possesses strong knowledge/expertise of community resources, facilities and programs that accept complex patients for treatment and/or placement. Demonstrates effective verbal and written communication skills with staff, patients, families, visitors, and other health care team members. Maintains familiarity with all hospital and department specific policies and procedures.
Maintains professional competency for self through formal or informal continuing education, attending professional conferences, professional association affiliation/membership, etc. Proficient in use of the electronic medical record. Working knowledge of social work scope of practice and current issues impacting healthcare.
Understanding of payer/reimbursement practices and regulations. Ability to assess the psychosocial needs and family dynamics of the patient and family / caregiver. Knowledge of mandatory reporting for suspected or actual cases of abuse and / or neglect.
Flexibility to meet needs in sometimes high demand and stressful situations.
Work
Five (5) years’ experience in medical social work, behavioral health, or community social work. Certification: Certified Case Manager (CCM) certification. Accredited Case Manager Social Worker (ACM-SW) certification.
Skills/Knowledge/Abilities: Knowledge of care transitions, case management, performance improvement and managed care reimbursement. Comprehensive knowledge of continuum-of-care post-acute community resources. Comprehensive knowledge of healthcare regulations and payer processes.
Comprehensive knowledge of admission and eligibility criteria for home health, skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), and long-term acute care hospitals (LTAC). PHYSICAL REQUIREMENTS Majority of time involves sitting or standing; occasional walking, bending, and stooping. Long periods of computer time or at workstation.
Light work that may include lifting or moving objects up to 20 pounds with or without assistance. May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise. Communicating with others to exchange information.
Visual acuity and hand-eye coordination to perform tasks. Workspace may vary from open to confined. May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.
Benefits ABOUT HEALTH FIRST At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results.
As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.
Full-Time Paygrade : PG-36