As our PRN Social Worker, you will be a compassionate advocate, providing vital support and guidance to individuals and families facing complex challenges.
Every day, you will conduct psychosocial assessments, develop care plans, provide counseling and crisis intervention, and connect clients to resources. You'll advocate for clients and collaborate with multidisciplinary teams to ensure holistic support and promote well-being.
To be successful in this role, you will possess exceptional interpersonal skills, empathy, strong knowledge of community resources, and proven crisis management abilities, fostering positive change and client empowerment.
- 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.
