Job Description

Social Worker at Bryan Health summary:

The Social Worker collaborates with interdisciplinary teams to assess clients' medical, psychological, emotional, and social needs, facilitating goal setting and access to necessary services. Responsibilities include psychosocial assessments, discharge planning, case management, and patient/family advocacy across diverse populations. The role requires coordinating care within hospital systems, participating in quality improvement activities, and ensuring patients’ post-discharge needs are met.

Summary

The role of the social worker would be to work in conjunction with the Care Coordination team and other member of the interdisciplinary team. Social workers help clients by assessing their situation, setting goals, and obtaining required services. Help determine the nature of specific clients situations by assessing medical, psychological, emotional, and social information.

• Helps patients make informed decisions by acting as their advocate regarding patient clinical status and treatment options.
• Ability to perform a psychosocial assessment and reassessment on all patients. Assess and address motivational and psychosocial issues. This includes obstetrics, pediatric, adolescent, geriatric and the general patient population.
• Maintains open communication interdepartmentally and interdisciplinarily.
• Assures that social service/discharge planning activities are integrated and coordinated within the hospital system by effective communication at all levels.
• General knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage.
• Handle case assignments, review concurrent case progress, and have the ability to adjust plans accordingly.
• Record and document case information, complete accurately all necessary forms and produce statistical reports.
• Interacts professionally with patient/family and involves patient/family in the formation of the plan of care.
• Is knowledgeable of patients financial status, diagnosis and discharge needs.
• Formulates a teaching plan based upon identified learning needs and evaluates effectiveness of learning, family is included in teaching as appropriate.
• Accurately determines type of assistance/setting/resources necessary for the patient/family and provides appropriate resources/assistance list of facilities.
• Is responsible for home care needs being met by the time of discharge, with a goal of arrangements completed 24 hours prior to discharge when date of discharge is known.
• Prepares patients discharge by reviewing and amplifying discharge plans; coordinating discharge and post discharge requirements; orienting and training family members; providing resources.
• Actively participates in Utilization Review Committee, QI, varying team meetings and other meetings as appropriate.
• Consults other departments as appropriate to collaborate on patient care and performance improvement activities.
• Performs and evaluates mental health, drug, and ETOH assessments.
• Ability to submit and interpret PreAdmission Screening and Resident Review (PASRR).

Education/Experience:

• Bachelors degree in social work required; Masters degree in social work from an accredited university preferred.
• Current State Social Work Licensure.
• BLS required within 6 months of hire.
• General knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage preferred.

Keywords:

social work, psychosocial assessment, case management, discharge planning, patient advocacy, care coordination, mental health assessment, utilization review, Medicare Medicaid knowledge, hospital social services

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