Complex Care Social Worker

The Complex Care Social Worker is responsible for non-clinical, biopsychosocial assessments and interventions as needed for both the inpatient floors and the outpatient emergency department. The MSW performs crisis intervention, patient/family interventions, high risk screening, focused emotional supports, and referrals for financial assistance or other identified resource needs. The MSW will also assist in post-acute care placement on all discharges, primarily with those patients identified with post-discharge behavioral health and patient assistance/resource needs, and arranges and facilitates Family Care Conferences to support patient, family, and discharge planning goals. The MSW is dedicated to patient and family centered care that values personal self-determination, prioritization, and engaging in creative, compassionate problem-solving. The MSW maintains a thorough working knowledge of the rules of Medicare, Medicaid, and private payer regulations and processes, and possesses a thorough understanding of managed-care concepts and length-of-stay management relating to patient and organizational fiscal responsibility. 

The scope of this role includes intensive care units, Trauma, Oncology, NICU, Transplant, ED, and responds to physician, non-discharge planning social work consults throughout the facility.

Major Responsibilities:

• Works collaboratively with RN case managers, acute care nurses, physicians, insurance companies, and other staff members to proactively identify and address patient needs. Maintains effective communication between members of the care team.
• Identifies and addresses barriers to discharge and recovery, including financial, emotional, psychosocial, medical, and spiritual.
• Performs thorough assessments and develops appropriate discharge plans for high-risk patients with discharge planning or psychosocial needs.
• Obtains input from the RN case manager to ensure the discharge plan is appropriate and aligns with the patient care plan. Reassesses and modifies patient discharge plan as needed, in conjunction with the clinical team.
• Participates in the interdisciplinary care planning process and performs proactive discharge planning.
• Provides education to patients and caregivers regarding community resources and post-acute level of care criteria, benefits, and coverage.
• Coordinates and facilitates meetings between the care team and patients/families/caregivers. Assists patients and families in making difficult decisions while honoring their preferences and values.
• Engages in community outreach and program development to support patients/families/caregivers.
• Provides expertise in post-acute services and community resources.
• Demonstrates knowledge of patient rights, advance directives, ethical issues, and confidentiality requirements.
• Provides expertise in ethics cases.
• Responds promptly to referrals from RN CM or other staff who identify risk factors for social determinants of health, emotional support, and coping.
• Intervenes with patients/families/caregivers for psychosocial needs, assistance, and support in coping with chronic acute terminal illness. Engages in consultation, discharge planning, education, counseling, advocacy, and information referrals to meet the emotional, social, and financial aspects of care.
• Provides emotional support to patients and family members during complex and/or emotionally charged issues, such as end of life, terminal illness notifications, death notification (with physician), and crisis interventions.
• Complies with all facility and regulatory policies and standards related to ethical practices and discharge planning.
• Performs other duties as assigned.
• Practices and adheres to the “Code of Conduct” and “Mission and Value Statement.”

Education/License Requirements:

• Master's degree in Social Work
• 1+ years experience or MSW internship
• Currently licensed as a Registered Master of Social Work per state requirements or Licensed Clinical Social Worker preferred
• Certification in Social Work preferred