Job Description

Assesses, plans, and coordinates services and resources for patients and families to meet needs and/or provide for timely discharge.
Education

• Master\'s degree in Social Work from a school accredited by the Council on Social Work. required

Experience

• 1-2 years Experience in social work in a hospital, inpatient psychiatric or medical/health setting or area of specialty preferred

Licenses and Certifications

• Valid Social Worker license in the State of Maryland. required and
• CPR/BLS certification preferred

Knowledge, Skills, and Abilities

• Diagnostic and problem-solving skills.
• Psychosocial assessment and advocacy skills.
• Verbal and written communication skills.
• Basic computer skills.
• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
• Collaborates with and completes referrals to appropriate community agencies for assistance based on patient need. Initiates referrals in a timely manner. Uses responses to help patient resume life in the community and/or adjust to lifestyle changes.
• Communicates daily with direct caregivers and case management triad regarding patient and family responses to plan of care, identification of problems, discharge planning, and payor concerns such as LOS. Identifies delays in care and quality/risk issues and communicates information to appropriate individuals and departments.
• Completes psychosocial history or socioeconomic assessment as determined by healthcare team or high-risk indicators.
• Coordinates the completion of requisite forms by doctors, patients, and patients\' families for any services required.
• Maintains accurate and timely documentation of case management activities to assure that physicians and caregivers are well informed regarding the discharge plans. Adheres to all policies and procedures regarding documentation and confidentiality of information.
• Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team.
• Demonstrates knowledge of community resources serving the high social risk populations.
• Develops and maintains information on community resources and referral requirements based on patient population as identified in the unit scope of practice.
• Facilitates communication between the patient and family and the healthcare team. Assesses and communicates the patient\'s social, cultural, emotional, and economic problems to medical staff and other healthcare providers as needed. Effectively intervenes with patient/family in resolving emotional/behavioral obstacles to patient\'s progress, recovery, and disposition.
• Initiates and participates in multidisciplinary discharge planning rounds and collaborates with internal and external health care providers, patient and family to develop comprehensive discharge plans.
• Maintains own professional growth in the area of managed care, care management, other health care, financial trends, clinical practice and research.
• Organizes individual workload and sets appropriate priorities based on patient\'s medical plan, patient\'s needs, and policy and procedures.
• Provides crisis intervention and management. Provides therapeutic intervention with patients and family including individuals, marital, parental, family and group therapies.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
• Participates in multi-disciplinary quality and service improvement teams.
• Advocates for the patient and family throughout the entire episode of care. Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered. Assesses and assists patient in referral and application for funding sources and eligibility for entitlement programs. Assists patients in the exercise of their rights while encouraging patient autonomy and participation in their care. Assists patients and families in adjusting to episodes of acute and chronic illness, in coping with lifestyle changes precipitated by illness or injury, and in addressing issues of terminal illness. Completes timely and appropriate documentation.
• Conducts timely psychosocial assessment interviews with minimally all high risk or complex cases and other patients and families to identify problems requiring social work interventions and plans for appropriate services. Explores the need for guardianship and other legal proceedings. Maintains strict standards for patient confidentiality and patient related information in addition to security of electronic (computer) information. Complies with department, hospital, Peer Review Organization (PRO) and Maryland State regulations and policies on confidentiality. Participates in departmental monitoring and statistical reporting requirements as well as facility-wide performance improvement efforts.
• Professional Development: Attends in-service and training program to maintain and expand clinical skills and knowledge, serves as an interdisciplinary team member on committees, and, participates in patient, staff, facility and community education programs including supervision of students as assigned. Provides consultation to other disciplines when psychosocial aspects of care or coordination with significant or intensive community resources are necessary to achieve desired treatment outcomes. Provides counseling to impact problems related to the environmental needs, family and interpersonal conflict (such as domestic violence, child and elder care abuse), or physical and mental illness using a variety of treatment modalities, including individual, family, group, or specialized counseling. Utilizes clinical skills in crisis situation to resolve conflicts.Works collaboratively and maintains active communication with physicians, nursing staff, case manager, and other members of the multidisciplinary care team to effect timely, appropriate patient management through the continuum of care.

MedStar Health