Medical Social Worker

Job Summary

Reports directly to the Director of Social Service. Medical Social Worker assignment includes primary responsibility for coverage of Acute Care Cases, Outpatient, and Behavioral Health areas. Responsible for provision of social work intervention for cases assigned; customizes care plans based on individual patient care need timely and efficiently. Social Work focuses on the social determinants of health that may be an issue; assist with dc planning activity as indicated; care plans based on individual patient care need timely and efficiently. Responsible for information and referral services; provides counseling, supportive services and post discharge follow up as indicated. Works with patient and families navigating through the healthcare system promoting advocacy and education; included but not limited to data collection, statistics on caseload activity and reporting weekly and monthly reports to the director timely and efficiently; support groups, outpatient inquiries etc and other duties as assigned by the Director.

Job Requirements

Minimum Education

• Associates Degree required, Bachelor's Degree preferred in SW or related field

Minimum Work Experience

• Min. 1-3 yrs. experience in hospital setting, SNF, or health/community agency

Minimum Licenses and Certifications

• Social Workers MA State SW licensure-LCSW, LSW, LSWA and /or LICSW

Required Skills

• Ability to work independently and with a team
• Excellent verbal and written communication skills required
• Computer experience for data collection, report writing, and quality monitoring
• Ability to work with community agencies to mobilize resources requited
• Demonstrates flexibility and adaptability to change

Functional Demands

Physical Requirements:

Exerts up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. Frequently reaches (extending hands and arms in any direction), and handles (seizing, holding, grasping, turning, or working with hands).

Organizational Expectations

Behavioral Attributes:

The following behavioral attributes are required: achievement motivation, concern for order, flexibility, initiative, self-confidence, customer service oriented, interpersonal effectiveness, teamwork, analytical thinking and information seeking.

Essential Functions

• Reports directly to the Director of Social Service and Indirectly reports to Unit Manager and Practice Leader. Works collaboratively with unit team and responds timely, efficiently and respectfully
• Keeps department director abreast of any issues, trends identified and/or needs weekly and/or more frequently if needed
• Demonstrates professionalism and teamwork. Covers for co-workers during planned and un-planned absences and as requested by director.
• Provides service to community at large through the provision of service to Walk-In and telephone inquires as assigned by Director and/or designee as needed
• Completes the Assessment fully, clearly, concisely, and within 48 working hours of being assigned the case
• Completes clear and concise documentation noting patient and family participation, multidisciplinary involvement, and other planning information as required by the department, as well as, state and federal regulation agencies
• Communication: builds rapport and responds to needs of physician, healthcare team members, 3rd party payers, referral sources and vendors to enhance internal and external customer service satisfaction
• Conducts High Risk Screening on all patients on assigned units for potential needs as per policy
• Assists with discharge planning process assuring services/ placement is appropriate in the continuum of care with PASARR, OBRA, Level of Care form completion etc and are completed timely and efficiently as per regulatory standards
• Informs patients of their patient rights when indicated (i.e. discharge planning, URCO ,and appeal process, guardianship, court commitments, admission/hospitalization status, Power of Attorney and Conservatorship; Advanced Directives/Healthcare Proxy, Interpreter Services etc
• Provides information and education to patients and their families regarding the care plan as part of their specific care needs and works closely with members of the multidisciplinary team including, physicians, patients, families, hospital staff and community agencies
• Casework statistics are completed and submitted to department secretary within 5 days post discharge
• Conducts post discharge follow up on High Risk patients in an attempt to reduce re-hospitalization

• Completes discharge planning assessments timely, efficiently and completely following regulatory standards and departmental policies assuring appropriate patient flow. Appropriately levels patient for home discharge with or without services or to another type of facility such as a SNF, Acute Rehab etc. Develops coordinates and implements discharge plan on cases assigned with patient and/or family/so caregiver. Identifying patient preference and selection choice for HHA/SNF placements having patient preference form checked off and signed/dates by patient and/or so. When plan is in place, notify provider establish and determine anticipated readiness for discharge, keeping patient/family/so informed and documenting such in the EMR. Closes case out using appropriate forms for transition of care communication timely and efficiently.Collaborates with the team to assist the Multidisciplinary Team in providing discharge planning activities to assist in expediting a patient’s discharge as part of the care transitions process. It is the expectation that the Social Worker remains current and proficient in the discharge planning process

• Participates in discharge planning rounds daily. Works collaboratively with multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, addresses potential needs, resources, referrals for other disciplines and services. In a positive professional manner

• Providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations for concurrent reviews and for prior authorizations as they pertain to discharge planning activities and case management. Demonstrating timely and efficient service. When indicated

• Participates in performance improvement activities and other projects as assigned by director. Completes a statistical record of each case closed, noting recorded hours, contacts made and services provided so that department documentation and statistics can be completed.All cases are to be submitted to the department for the previous month no later than within 5th day of the new month. It is the expectation that Statistical Sheets are accurate and complete upon submission

Statement of Other Duties

This document describes the major duties and responsibilities for this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described.