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R-23576

Facility:

LOC0020 - 143 Longwater Norwell143 Longwater Drive Norwell, MA 02061

SSH Population Health

Full time

40

Day (United States of America)

The Clinical Social Worker acts as a patient advocate to SSH & SSMC clients. Works in coordination with the RN Case Manager to coordinate, negotiate, procure services and resources for and manage the transitional care planning of patients to facilitate achievement of quality and cost-effective patient outcomes.
Responsible to work with a multi-disciplinary patient care team to optimize care coordination, behavioral and mental health and wellness, monitor patients through admissions, ED visits and collaborate with other stakeholders to transition home/to the community post discharge. This role requires varying degrees of follow-up and follow through, including fostering, executing, and expediting efficient care coordination and assessing the needs of patients and families.
Works collaboratively with the interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. Utilizes SMART GOAL formation and clear, precise documentation regarding patient outcomes and interventions. The Social Worker is on site and available 4-5 days a week as well as some holidays; no nights, weekends or on-call hours required.

Compensation Pay Range:

$73,000.00 - $104,400.00

 

Patient Contact

Does this position have Patient contact? Yes

Age of Patient(s) - (check all that apply)

• Adolescents 13 - 18 yrs YES
• Children 1 - 12 years YES
• Adults 19 - 70 years YES
• Geriatrics 70+ years YES

Minimum Education - Preferred

Master's required. Must be independently licensed. Demonstrates competency in basic computer and keyboard skills required, EPIC and Outlook preferred. Knowledge of basic medical terminology preferred.

Minimum Work Experience

Recent healthcare experience or related field preferred. Experience working with pediatric patients and families, elders and their caregivers, and/or various other community populations desirable. Social worker experience required.

Required Licenses

LICSW – Independently Licensed Certified Social Worker or

LMHC – Must be independently licensed

Required additional Knowledge and Abilities

Excellent communication skills required: ability to work independently and autonomously. Ability to manage time, set priorities and self-origination will be essential to success of employee. Ability to work within a multidisciplinary team and in collaboration with the RN Case Manager and supporting staff.

Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions that the person in the job is held accountable for. Following are the essential functions of the job.

1 – SSMC Referrals

a - Respond to and prioritize urgent high-risk cases such as

• Crisis interventions
• Depression Screening referrals
• Pedi BH referrals
• Adult Protective Service (APS) and/or Child Protective Service (CPS) referrals
• Guardianship referrals

b - Coordinate appropriate community and resource specific referrals

• Financial
• Educational
• Counseling/family support agencies

C - Complete and document initial psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission/one business day or within 24 hours of referral

2 – CMS TEAMS

a – Review work list/census to prioritize patients and identify those that meet criteria for social work interventions as needed; (attending Monday morning CMS Teams Huddle on upcoming patients)

b – Review patients in settings:

• ED when necessary
• Skilled Nursing Facilities – as needed for staff consult
• Coordination with VNA/Home Health or Family support when patient has been discharged home

c – If discharge plan initiated, verify demographics and insurance information is correct

d - Coordinate with CMs in various departments to ensure continuity of care and support

e - Complete and document initial psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission/one business day or within 24 hours of referral

• Follow progress of patient from Pre-surgical teaching/planning through 30 day post-procedure episode
• SW may be asked to be involved in discharge and or transition planning for CMS Teams patients across their episodic surgical journey

4 – Interdisciplinary Rounds

a - Attend and actively participate in IDRs for assigned units

b - Report during IDRs

• Patient's insurance
• Psychosocial barriers
• Anticipated Plan of Care
• Patient/family concerns
• Follow-up items for SW/CM

c - Identify patients that would benefit from SW intervention or support

d - Report resource limitations on post-acute care benefits or denials that could impact the discharge planning

e - Document avoidable delays identified during IDRs

5 – Communication and Coordination

a - Communicate with care team (Physician, Provider, Nursing Staff, Ancillary) about identified psychosocial issues or barriers that might delay or prevent timely discharge

b - Update CM counterparts/care team daily or more often if necessary

c – Collaborate with internal team and external agencies to coordinate care and timely discharge:

• Facilitate patient care conferences and patient/family meetings
• Coordinate with APS/CPS agency personal and assist with meetings
• Coordinate with legal system (guardianship/adoption

d - Ensure patient/family is updated and involved in the care plan

6 - Escalation

a - Escalate to Case Management leadership and/or Physician Advisor (PA)

b - Escalate all high-risk cases that will require additional attention or resources in order to remove risks and barriers to a timely discharge

7 – Regulatory Requirements

a - Provide when appropriate the following regulatory notifications: Medicare Outpatient Observation Notification (MOON), Important Message from Medicare (IMM), Detailed Notice of Discharge (DND), Hospital-Issued of Non-Coverage (HINN) Advance Beneficiary Notice (ABN)

Technology and Learning

a - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role.

Indicate the appropriate physical requirements of this job in the course of a shift.

General Activity -  Frequent Standing/Walking Required, No Driving

Motion -  Infrequent Activity Required-pushing, pulling, lifting, bending

Motor Skills -  Use of hands required, Use of feet required

Weight/Force -  Light lifting required (<25lbs)

Body Fluid Exposure -  Yes

M-F 8:30am -5pm

Licensed Independent Clinical Social Worker - Board of Registration of Social Workers (Massachusetts)