Performs a variety of services with all patient populations including psychosocial needs assessments patient / family education regarding community state and federal resources. Provides counseling to patients and families about impact of hospitalization and illness on well being.
- Minimum MSW or equivalent
- 1-3 years experience
Assesses all patients referred for social work case management services. Referrals are received from physician orders; nursing orders; multidisciplinary rounds; patient / family requests and community agencies.
Prescreening for high risk patients is routinely performed via census review and multidisciplinary rounds.
Performs needs assessments; prioritizes patients' needs / choices; and collaborates with the interdisciplinary team; patient / pertinent other; and community resources in order to fully develop/organize treatment plans with optimal outcomes.
Coordinates plans with patient / family; members of the health care team utilizing best practice approaches. Performs on-going evaluation / readjustment of plans for efficacy; quality; cost effectiveness; and goals / outcomes.
Serves as patient liaison / advocate between care providers; community agencies; and insurance payers.
Advocates for services and funding necessary to meet established outcomes. Maintains working knowledge of payer requirements.
Provides supportive counseling and crisis intervention and advocacy to patients and families. Works in close collaboration with nurse case manager on all cases and; in particular; cases involving complex biopsychosocial / legal / financial issues to establish and review plan of care.
Prepares and maintains required documentation for each case. Complies with State and Federal mandates for documentation and reporting.