Performs a variety of services with all patient populations, including psychosocial needs assessments, patient/family education regarding community, state, and federal resources.
Provides counseling to patients and families about the impact of hospitalization and illness on well-being.
Requirements:
• Minimum MSW degree or equivalent • 1-3 years of experience
Major Responsibilities:
Assesses all patients referred for social work case management services. Referrals are received from physician orders; nursing orders; multidisciplinary rounds; patient/family requests, and community agencies.
Prescreening for high-risk patients is routinely performed via census review and multidisciplinary rounds.
Performs needs assessments; prioritizes patients needs/choices; and collaborates with the interdisciplinary team, patient/pertinent other, and community resources in order to fully develop/organize treatment plans with optimal outcomes.
Coordinates plans with patient/family; members of the health care team utilizing best practice approaches.
Performs on-going evaluation/readjustment of plans for efficacy; quality; cost effectiveness; and goals/outcomes.
Serves as patient liaison/advocate between care providers; community agencies; and insurance payers.
Advocates for services and funding necessary to meet established outcomes.
Maintains working knowledge of payer requirements.
Additional Responsibilities:
Provides supportive counseling and crisis intervention and advocacy to patients and families.
Works in close collaboration with nurse case manager on all cases and, in particular, cases involving complex biopsychosocial/legal/financial issues to establish and review plan of care.
Prepares and maintains required documentation for each case.
Compliance:
Complies with State and Federal mandates for documentation and reporting.