Job Description

Certification Details

• Licensed Clinical Social Worker (LCSW)
• Basic Life Support (BLS)

Job Details

• Responsible for coordinating and implementing post-discharge plans in coordination with the Case Managers through the use of Extended Care Information Network (ECIN).
• Assists with advocacy and referrals to other community resources.
• Obtains, reviews and analyzes information relative to discharge planning in accordance with hospital policy.
• Assesses/reassesses patient's clinical and psychosocial status, premorbid status, community services utilized, and diagnosis and treatment plan per Case Management referral.
• Identifies community resources needed and facilitates referrals to agencies or programs for assistance as needed.
• Educates patient and/or family on community resources available for assistance.
• Facilitates discharge planning working with patient, families and treatment team making needed referrals/arrangements and documenting actions.
• Documents actions taken in progress notes and/or discharge planning-assessment form from initial visit through to discharge.
• Demonstrates professionalism in actions and job performance in accordance with mission and the social work code of ethics.
• Demonstrates and understands the needs of neonatal, pediatric, adolescent, geriatric age groups and implements discharge plans tailored to age-specific needs.
• Demonstrates sensitivity toward different age groups, ethnic, cultural and disabling human diversity and human development.
• Conforms to standards of patient and family confidentiality according to hospital and NASW standards and HIPAA.
• Assesses patient's physical, psychosocial, cultural and spiritual needs through observation, interview, review of records and interfacing with interdisciplinary team and caregivers to ensure appropriate referrals.
• Reevaluates and makes adjustments to discharge plan as patient's condition changes.
• Ensures appropriate arrangements for post-hospital care are made before discharge to avoid unnecessary delays.
• Assesses patient/family emotional, social and financial needs and assists in setting up community resources to meet these needs.
• Provides support to patients and families coping with changing medical conditions.
• Confirms treatment goals and anticipated plan of care through discussions with treatment team and review of documentation.
• Communicates treatment goals or best practices to treatment team including physician.
• Uses ECIN to facilitate electronic referrals for discharge planning.
• Uses supportive crisis intervention including illness, grief/loss in decision making process.
• Consults and communicates with manager regarding difficult practice issues.
• Adheres to state and federal regulations pertaining to discharge.
• Implements discharge plan in accordance with physician direction and patient/caregiver agreement.
• Assesses patient/family learning style and appropriately teaches and documents understanding.
• Collaborates with interdisciplinary team to develop and implement holistic, individualized plan of care.

Job Requirements

• Knowledge of community resources used for discharge planning.
• Knowledge of hospital operations.
• Excellent communication and presentation skills.
• Knowledge of third party payment systems, Medicare/Medicaid programs.
• Ability to multi-task, set priorities and maintain organization.
• Computer skills.

Additional Details

• Works in collaboration with Case Management Coordinator, Home Care Coordinator and Utilization Review to ensure seamless and timely delivery of services.
• Maintains updated referral resource lists.
• Assesses, coordinates and evaluates discharge readiness with Case Management and discusses variances with treatment team as needed.
• Participates in Family Conferences and Interdisciplinary Team Meetings as needed with Case Manager.
• Reviews variance in plan of care concerning discharge planning with Case Management and/or supervisor as needed.
• Completes daily discharge planning verbal rounds with Case Management department to prioritize daily activities.
• Initiates discharge planning day one of referral to assist with length of stay management.
• Works with third party payors and Case Management to satisfy discharge planning needs and obtain approval of post discharge plans.
• Implements plan and communicates possible options for discharge with regard to insurance benefits and contracted providers.
• Makes appropriate outside agency referrals.
• Follows through with all aspects of discharge planning across continuum of care.
• Provides supervision/preceptorship for department medical social workers pursuing advanced licensure.
• Performs SBIRT evaluations, biopsychosocial assessments and crisis evaluations.
• Maintains current knowledge base of community services through continuing education.
• Float may be required to any CommonSpirit location within 60 miles of original assignment or float zone.
• Float assignments may include duties outside of original assignment job requirements in accordance with CommonSpirit policy.

Job Tags

Similar Jobs