Social Worker (MSW) - Transitions of Care/PRN (Scheduled As Needed)

Job Summary :

Job Description

Essential Responsibilities:

*Note: While these are considered essential responsibilities of the position this is not a comprehensive inventory of all duties and does not take into considerations accommodations that may be required as situations arise.

* Discharge screening, evaluation, development and implementation of discharge plans with focus on those with complex needs.
* Reassessment of discharge plan and monitoring for changes in condition
* Patient advocacy with support persons and healthcare team if needed
* Interventions and support with family stress and emotional needs as it related to making appropriate healthcare decisions.
* Crisis intervention/adjustment to illness/bereavement
* Resource brokering (SNF, home care, hospice, infusion, LTAC, DME, etc)
* System integration/continuity of care and interdisciplinary collaboration
* Adoptions
* Follow up calls for per Transitions of Care Discharge Policy. Ability to assess patient care needs over the phone and apply interventions.
* Provision of resources to patients prior to or after admission to facilitate an effective discharge plan as patient care needs change and emerge.
* Chemical dependency and mental health assessments and referral to treatment
* Readmission assessments and trending.
* Provision of Medicare Notification Letters.
* Assistance with resolutions of financial concerns including linking to eligible programs and hospital assistance programs
* Abuse (adult, child, sexual, domestic violence) assessments and referrals.
* Assessment of Social Determinants of Health and ability to understand the manner in which a variety of government programs and social service agencies are organized and function and an ability to assist individuals with accessing those programs and services.
* Provides information and execution of advance directives.
* Participation in departmental, hospital and community meetings and initiatives relative to departmental scope as assigned.

The functions of this position are not limited to what has been listed; other tasks may be performed as assigned.

Education and Experience Required:

A Master of Social Work degree (M.S.W.) from a school with an accredited social work program and either:
1) educational emphasis on health care, including a field placement in a hospital social service department or other health care agency OR
2) previous work experience in a hospital social service department or other health care setting.
3) Behavioral health experience preferred

Mandatory Licensure/Certifications:

Valid and active Indiana Social Work licensure required.

Work Shift :

Scheduled Weekly Hours :