Master Social Worker

What You’ll Do

Position Summary

TheSenior Guiasystematically intervenes to provide clinical social work and complex case management to patients and their families who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies. This position assesses the patient’s plan of care and develops, implements, monitors, and documents the utilization of resources internally and externally and progress of the patient through the continuum of care. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This role participates in an interdisciplinary team (including Physicians, Case Managers, Staff Nurses and other members of the care team) to provide services for high risk patients and ensure that psychosocial needs are attended to and treated as required across the continuum of care.

Responsibilities

• Providescomprehensivecare coordination to an assigned patient caseload

• Works collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex medical patient needs

• As part of a multidisciplinary team, develops and carries out a treatment planby the use ofa clinical social work diagnosis,assessmentand treatment interventions

• Intervenes with patients and familiesregardingemotional, social, and financial consequences of illness and/or disability

• Assesses,mobilizesand provides follow up on family/community resources to meet social care needs

• Provides intervention in cases involving elder abuse/neglect, domestic violence, guardianship (temporary/permanent), mental health placement, and sexual assault

• Initiates andassistspatients with advance directives

• Collaborates with patients/caregivers to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs

• Formulates care plan of intervention acceptable to the patient, family, and health care team

• Receives referrals for complex patient problem resolution from case managers or clinical care team members

• Works in collaboration with the clinical and case management team on transitions of care planning and referrals topost acuteproviders

• Promotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and significant others to ensure the process of integrated care services are targeted,appropriate, and beneficial

• Advocatesutilizingknowledge of applicable laws, regulations, government, and insurance benefits as well as practice guidelines and standards of practice

• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system

• Providesfollow upandassistanceto patients in a variety of settings: in-home, in-clinic, and in the ancillary setting- hospitals, group homes, skilled nursing facilities, etc.

• Documents all interventions in the patient medical record bothtimelyand accurately including all elements of clinic visits, in home, telephonic engagement, or texting

• Maintains knowledge of Medicare, Medicaid, and other program benefits toassistpatients with resource allocation and choices

• Has freedom todeterminehow to bestaccomplishfunctions within established procedures

• Provides consultation tolow riskguiason patients with significant or intensive community resources needs

• Participates in the development and maintenance of case management metrics

• Provides professional education to staff and community

• FacilitatesSuvidasponsored support groups

• Other duties as assigned by Guia Manager

What You’ll Bring

Knowledge, Skills, and Abilities

• Acute inpatient hospital social work experience preferred

• Experience managing the needs of Senior/Geriatric populations

• Experience assessing and addressing the social determinant of health

• Working knowledge of ICD-10 and Z codes

• Proficiencywith EMRs, computers, mobile devices, medical devices, and Microsoft Office Suite

• Excellent therapeutic communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues

• Exposure and/or experience in pre-acute and post-acute care

• Expertise