As our Care Coordination Social Worker MSW, you will drive patient well-being and resource navigation, directly impacting the holistic care and successful transitions for hospitalized and emergency department patients. You will serve as a critical member of the Care Coordination and multidisciplinary healthcare teams, ensuring comprehensive support and linkage to essential resources.
Every day you will be responsible for performing social work screenings and interventions for hospitalized and emergency department patients, in consultation with as needed and collaboratively with the Care Coordination and multidisciplinary healthcare teams. Your functions will include providing patient/family support and making appropriate referrals, conducting thorough social needs screenings, and facilitating referrals for financial or other identified resource needs. You will skillfully arrange family/patient representative meetings with the healthcare team as needed, assist in the post-acute placement of complex discharges, and engage appropriate agencies or community resources when patient's social needs are identified.
To be successful in this role, you will possess strong social work assessment, intervention, and collaboration skills, with an unwavering commitment to patient advocacy, resourcefulness, and our organizational values. Your professional demeanor, dedication, and proactive approach are essential for fostering effective patient/family support, navigating complex social determinants of health, and ensuring seamless transitions of care for diverse patient populations.
- Providing developmentally appropriate care for all populations served: plan for the safe discharge and continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients.
- Advocacy and education: patient/family support; patient/family health management education; healthcare team and community education; case/care management/coordination education and training; social needs identification and referral.
- Complex social needs management: social needs screenings; determination of patient functioning and availability of support systems; support in addressing social needs and making related referrals; escalation of identified cases involving abuse, neglect, trafficking, complex family issues affecting care, grief/bereavement support (individual and group), adoptions, surrogacy, safe surrender, substance use and abuse, and significant mental health or psychiatric concerns; addressing, managing, and referring resources related to social
determinants of health (e.g. housing and food insecurity, transportation). - Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning
and management; share in responsibility for identifying appropriate decision makers if the patient is unable or without capacity. - Discharge/Transition Management: as member of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to social work scope of practice; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; assistance in referral and management of grave disability, palliative care/end-of-life, and hospice patient/family needs; interventions, management, and coordination of discharge/transition planning for socially complex cases.
- Community Resource Coordination: life-care planning; consultation on healthcare resources; team and patient education regarding
various healthcare-related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social needs.
