Provides professional clinical social work and discharge planning services as appropriate to individuals, families, and groups in the assigned social work area. Works with the social, emotional, and related financial problems precipitated by or resulting from illness, medical treatment and/or hospitalization.

Responsibilities:

Performs patient evaluations, assesses needs and contributes to the Plan of Care

• Initiates patient psychosocial assessment as per department policy
• Incorporates High Risk Screening to assist in determining patient’s need for discharge planning services
• Develops measurable goals related to the problem areas
• Provides counseling to patient/family related to adjustment to medical condition, change in level of independence, palliative care, hospice, and financial consideration, such as long term follow up and care
• Provides appropriate information to managed care companies and other payers to obtain necessary authorization or approval as needed/requested
• Is knowledgeable and able to assist and advocate for the patient when inappropriately denied for necessary services/entitlements
• Attends daily/weekly discharge planning rounds, SNAP Huddles and Escalation Huddles as appropriate on assigned patient care units to communicate discharge planning needs.

Implements and/or Supervises implementation of the Plan Of Care

• Develops and implements appropriate and safe discharge plan with patient/family/caregiver/physician/other healthcare team members based on recommendations and social situation
• Provides/offers supportive services to patients and their family/significant other/caregiver regarding medical/functional condition including palliative care, hospice, crisis intervention and counseling service when appropriate
• Coordinates and facilitates family meetings as needed
• Ensures that patients have appropriate post-acute care plan in place prior to discharge by making referrals for appropriate post-acute care and services such as Support Groups, Home Care Services, Outpatient Clinics, Therapy, Palliative Care, Dialysis, Group Home, Assisted Living, Adult Home, Hospice (in-patient and home settings), Patient/Home, or Skilled Nursing Facility.
• Arranges transportation for patients when appropriate and obtains necessary authorizations or documentation of payment method
• Documents initial psychosocial assessment in a timely manner as per department standards

Documents in a timely fashion patient progress toward established goals

• Documents patient progress toward discharge planning goals
• Documents pertinent interaction with patient, family, insurance, referral sources, other health care facilities, community resources as per department policy
• Updates the discharge plan at least once per week per department policy
• Documents clearly written assessment and discharge plans in medical record
•  Documents on Care Maps/Team Conference Sheets and /or any other chart forms when applicable
• Documents patient education activates on the Patient Education Record  

Prepares patient for discharge to the next level of care

• Is knowledgeable of patient’s resources in planning for discharge and discusses these with patient/family members/caregiver
• Initiates/facilitates referrals for all post-acute needs
• Processes the necessary paper work to managed care company, post-acute provider, community agency to secure authorization, approval, acceptance, etc. to the next level of care
• Assists patient/family/caregiver/team with a timely discharge and smooth transition

Requirements:

Education: Masters of Social Work from accredited School of Social Work and LMSW.

Licensure/Certification: New York State Social Work Licensure required

Skills, Knowledge or Abilities:

• Knowledge of basic computer skills, EPIC and Midas documentation.
• Ability to effectively communicate with all levels of staff in a verbal or written manner.
• Ability to organize information
  • Knowledge of all rules and regulations of child abuse/neglect reporting as appropriate.
  • • Documented experience and knowledge of two direct practice modalities.
    • Excellent oral and written communication skills.
    • Excellent interpersonal skills
• Must read, write and speak English to the extent required by position; knowledge of Spanish language preferred

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, differential pay or other forms of compensation that may be applicable to this job and it does not include the value of benefits.