Social Worker - Medical Outpatient

The Medical Social Worker works under the supervision of the Director as a participative member of the interdisciplinary team. The Medical Social Worker is responsible for assisting with care management in multiple settings. The Medical Social Worker is responsible for identifying psychosocially complex patients who meet high risk criteria and would likely benefit from coordination of care. This includes: collaborating with individuals and their families using the CM process for assessing needs, developing plan of care, coordinating delivery of services, monitoring changes, and reassessing the person's needs on a regular basis. The Medical Social Worker works in collaboration with RN and Care Coordinator across departments within the acute care setting and with community agencies. The Medical Social Worker will collaborate with providers across the continuum of care; facilitating the coordinated utilization of resources for maximization of health outcomes, patient/family satisfaction and financial outcomes.

Responsibilities

• Identifies patients/families with psychosocial barriers to health care resources and basic needs impacting their well-being.
• Maintains awareness/understanding of reimbursement methodologies of various payer groups and serves as a resource regarding government benefit programs (Medicare, Medicaid, VA, etc). The BSW will also assist patients in the navigation of benefit structures and financial resources. Coordinates financial assistance access.
• Assess, plan, develop, and facilitate appropriate services and resources. This will include collaboration with physicians, patients, families, and the IDT to prevent delays in care, increased LOS, and avoidable readmissions. The Medical Social worker will complete documentation of assessments and interventions in the medical record and other records as required.
• Assists with developing and implementing complex discharge/transition plans (home, long-term care or other healthcare facility disposition).
• Maintains knowledge of community and organizational resources available to meet the needs of customers including post-acute LOC requirements and options.
• Demonstrates collaboration with Care Managers and other IDT members through consultation or referral as appropriate, as well as participating in process improvement activities.
• Provides emotional support and short term supportive intervention to patients and their families throughout the system.
• Gathers the “story” of the patient through initial assessment and ongoing monitoring and reassessment and makes appropriate referrals to IDT members. The BSW communicates the patient “story” effectively with physicians, peers, leadership, and external agencies
• Completes documentation in the electronic medical record as necessary.
• Leads/assists in community outreach events and provides education to the patient.
• Other duties as assigned

• Bachelor's Degree - Social Work Degree - Required

• 2 Years - Experience of BSW or Two semester practicum training at Mosaic Life Care - Required
• 3 Years - If position is in a Mental\Behavioral health setting must have minimum of three years’ experience in similar setting and certification by the National Association of Social Workers. - Required

• Upon Hire

• Must be able to travel between various system facilities and off-site locations as needed. - Required

Qualifications

Essential Technical/Motor Skills

• Hand/eye coordination; speaks clearly; good hearing, ability to use computers, printers and telephone equipment

Interpersonal Skills

• Must be able to teach, provide accurate and concise information, answer questions, maintain positive relationships with multiple customers, motivate and persuade others.

Essential Physical Requirements

• Physical requirements include sufficient strength and mobility to sit for long periods of time

Essential Mental Abilities

• Assess, comprehend, understand, interpret data to assess patient condition and evaluate care of patient.

Essential Sensory Requirements

• Appropriate functional vision, hearing acuity and smell

Exposure to Hazards

Other Skills and Abilities

• Transportation or driving to and from various locations for the purpose of coordinating member/patient care.