Position Summary: Supports psycho‐social needs of patients who are currently receiving out-patient care. The Social Worker strives to enhance an optimized level of health and/or recovery, provide interventions for populations ranging from infants to geriatrics, serves as a resource for the healthcare team, assists in identifying and facilitating discharge planning needs; and provides support/interventions in stressed filled situations. Education, License & Cert: Masters, Social Work New York State Clinical Social Work license required. Experience: A minimum of two years postgraduate experience as a Social Worker in a similar type of health care setting is strongly preferred. Successfully completing a 6-month practice-based orientation process is required . Essential Functions: + Provides psychosocial evaluation to meet the patient's medically related social needs. Such services include but are not limited to: + Assessment of the social and emotional factors related to the patient's illness, their need for care, their response to treatment, and adjustment to their care. + Assessment of the patient's medical and nursing requirements, home situation, financial resources, and the community resources available in making decisions regarding their treatment. + Participates in interdisciplinary conferences to identify patients and family needs. + Identifies problems and develops an optimal discharge plan based on the patient's needs. + Responds to consults as required by policy. + Facilitates discharge planning to meet the patient's needs for continued care (i.e., for skilled nursing, rehabilitation, acute care transfer, or other facilities). + Identifying psycho‐social, environmental, and financial problems that affect discharge planning. Collaborates with the healthcare team in establishing a treatment plan. + Consults with the RN Case Manager as necessary and requested. Completes timely, daily documentation patient's status in the medical record with who you are engaged. + Documents appropriately to reflect continuous progress in the plan of care: + Plan of care is documented fully as required. + Content reflects adequate details to enable extended members of the healthcare team to remain informed and able to implement plan. + Entries are timely, reflecting significant interactions/interventions that occur, by the end of each business day. + Documentation consists of all required regulatory components. + Assess and facilitate financial needs. Utilizes various charity funds available in a responsible manner according to policies/procedures. Assist patients and their families with applications such as disability papers, etc.). Collaborate with patients, Case Manager, Business Office, outside agencies, etc. to facilitate meeting financial needs. + Provides initial mental health evaluation, cognitive behavioral therapy, individualized/group therapy as indicated. Other Duties: This description is not intended to be all inclusive and other duties may be assigned as necessary in the performance of this position. Pay range min $27.58/hr max $43.70/hr Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community. The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace. The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.