Wage Range: $34.41 - $59.04 per hour. The amounts listed are the base pay range. Job offers are determined based on a candidate's years of relevant experience, applicable education and internal equity. Benefit Information: Choices that care for you and your family At EvergreenHealth Monroe, we appreciate our employees’ commitment and contribution to our success. We are proud to offer a suite of quality benefits and resources that are comprehensive, flexible, and competitive to help our staff and their loved ones maintain and improve health and financial well-being. + Paid Sick Leave + Employee Assistance Program + Cafeteria Discounts + Free parking OUR MISSION: EvergreenHealth will advance the health of the community it serves through our dedication to high-quality, safe, compassionate, and cost-effective health care. OUR VISION: EvergreenHealth will create an inclusive community health system that is the most trusted source for health care solutions OUR VALUES: Compassion - We care for and about our patients, families, and each other Respect - We respect the beliefs and values of everyone we encounter Excellence - We strive for excellence in all we do Collaboration - We work in partnership and believe every voice makes a difference Accountability - We are accountable to one another and to our community JOB SUMMARY: Working under department management, works in partnership with the Clinical Care Transitions Manager and other health care professionals to ensure continuity and coordination of care for patients and families. Provides consultation to patients / families regarding social, environmental, psychological, financial and cultural factors related to illness and hospitalization supports continuity in care management, and organizes all aspects of discharge planning. EDUCATION, TRAINING AND EXPERIENCE; CERTIFICATION/LICENSURE: REQUIRED for the position: + Must have a Master’s Degree in Social Work or related field. One of the following credentials is preferred: + Licensed Independent Clinical Social Worker (LICSW) + Licensed Advanced Social Worker (LASW) + Social Worker Associate License- (LSWAA) or (LSWAIC) + If hired prior to January 2012, then you may also have one of the following: + Licensed Mental Health Counselor (LMHC) + Licensed Mental Health Counselor Associate (LMHCA) + 2 years social work experience in an acute hospital setting or community setting. + Proficiency in reading, writing, comprehending and speaking English as required for business necessity. + Must have age-specific or behavior-specific knowledge and experience in working with specific patient populations (i.e., children, elderly, those with emotional / behavioral dysfunction) relevant to area of assignment. + Excellent organizational skills and be able to work under stress. + Excellent customer service and communication skills. + Self-directed and works well independently and as a team member. + Must have oral and written language skills, visual and aural skills in order to effectively communicate ensure, and provide for patient needs, and to provide a legal record of this care. + Accountability for professional practice, commitment to patient care, and commitment to uphold the Patient Bill of Rights. + Excellent customer relationship skills, interest and willingness to create and maintain relationships with all key customers, patients/families, physicians, payers, other departments, and outside agencies. SPECIAL EQUIPMENT, SKILLS OR OTHER REQUIREMENTS: Able to operate a variety of equipment. Must be able to use a personal computer, fax machine. Knowledge of local, state, and federal environmental and infection control regulations. Good customer service and quality improvement skills. Ability to compile, analyze and interpret medical data and forecast trends, implement protocols or standardization in collaboration with departments, managers, and medical staff. Ability to work well with others and communicate effectively, both orally and in writing. Shows good judgment; initiative and goal driven; ability to educate and provide just-in-time training. WORK ENVIRONMENT AND HAZARDS: Hazards include risk of exposure to communicable disease and BBP. Risk of injury from operating equipment. Risk of exposure to household and cleaning chemicals and hazardous materials and waste. WORK CONTACT GROUP: All departments, personnel, patients, visitors, and the public. SPECIAL PHYSICAL DEMANDS: Light to moderate lifting (minimum of 50 pounds). Must be able to bend, stoop, push, and pull. Variety between standing, walking, and sitting/computer work during the work day. JOB RESPONSIBILITIES/ESSENTIAL FUNCTIONS: + Provides supportive counseling to patients and families with regard to emotional adjustment to illness and manages assessment and referrals as needed. + Reviews each chart to determine patient discharge needs and options; coordinates all aspects of a safe, effective discharge plan in accordance with the needs and preferences of the patient. + Assists patient and family with information regarding local resources (SNF, DME, Home Care, etc.) and continuing care providers. + Facilitate third-party payment for discharge planning issues including DSHS applications. + Manages patient caseload, crossing all settings in which the patient receives care to include initiating contact with post-discharge care providers. + Attends patient rounds and works with the attending physician and the care management team and communicates the plan for discharge through documentation and active communication. + Provides consultation to medical and nursing staff regarding the psychosocial and mental status aspects of patient care. + Provide services in Emergency, PCU, and Medical Surgical settings. + Remains knowledgeable and current about available community resource and eligibility criteria for funding. + Assumes daily case load which will include identification of support resources, discharge planning, referral and resources, psychosocial interventions, and other support services, and documents in the patient record. + Provides psychosocial and behavioral health support for complex patient and family needs: crisis intervention, drug and alcohol assessment, bereavement services, and support to individuals or groups as referred or identified. + Maintains records of all patient contacts or those made on behalf of the patient and document all patient contacts as appropriate in the medical record. + Responds to emergent patient crisis situations, patient and/or family meetings, or patient planning sessions. + Assesses the need for community programs or resources. + Adheres to the National Association of Social Workers Code of Ethics and acts as a liaison between EvergreenHealth Monroe and outside authorities (DMHP, CDHP, DSHS) as needed/requested. + Participate in required meetings, conference calls, webinars, and educational sessions. + All other duties as assigned by supervisor.