Major Responsibilities:

Provides social work services to individuals or groups including: screening, psychosocial assessment, discharge planning, determination of social work goals, appropriate concrete and/or therapeutic interventions and follow-up.  Exercises a substantial degree of professional judgment, recognizing deviations from the usual patient/family functioning, anticipating problems and taking measures to maximize coping capabilities.

Conducts initial assessment and establishes a plan of care through psychosocial, financial, functional, and environmental data; establishes and follows a plan of care, which identifies problems and evaluates outcomes.  Provides ongoing assessment of patient/family needs and applies appropriate interventions. Updates and revises plan of care as indicated.

Plans for discharge from medical social services according to organization standards and utilizes internal systems and community resources to assure patient/family needs are being met.

Implements interventions substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources.  Initiates and coordinates interventions with the activities of other members of the health care team.  Collaborates with community agencies and institutions to plan continued care and to coordinate interventions related to finances, housing, childcare, family discord and other psychosocial problems.  Provides crisis intervention services.

Documents activity according to department and program protocols or standards.  Maintains and updates patient records according to organization, state, and federal guidelines.

Assists with managing utilization of resources especially as related to patients with complex continuity of care needs.

Provides education to patients/families regarding Advance Directives for health care decision-making.  Assists with execution of these documents as appropriate.

Communicates effectively with patients, family, other members of the health care team and community agencies and facilities resolution of issues which could impact on continuity of care (e.g., prior-approvals, application requirements, transfer paperwork).  Communicates with physician, care coordinator, other team members to collaborate and update plan of care.

Provides support to patient's family members in the case of a patient's death.

Establishes effective professional relationships, positively representing the social work profession throughout the organization and in the community.  Promotes constructive approach to problem solving.  Adheres to the professions Code of Ethics; consistently practices within a framework guided by ethical principles.

Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.  Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures.  Age-specific information is developed further in the departmental job standards.

Licensure, Registration and/or Certification Required:

Social Worker license issued by the state of Wisconsin, and

A valid drivers license issued by the Division of Motor Vehicles.

Education Required:

Master's Degree in Social Work.

Experience Required:

Typically requires 2 years of experience in social work that includes experiences in a home care or hospice environment.  

Knowledge, Skills & Abilities Required:

May be required (based on work location) to have a current driver's license granted by the state of residency with a driving record that meets Aurora fleet safety standards and proof of automobile liability insurance.

Must possess exceptional assessment skills.

Demonstrates exceptional understanding of family dynamics and psychosocial issues related to disability, acute and chronic illness and problems associated with advanced age.

Ability to provide short-term counseling to patients and their families.

Exceptional collaboration skills, advocacy abilities and ability to perform as a team player.

Exceptional knowledge of community resources and effective in accessing these resources.

Must possess above average time management skills to comply with productivity standards, patient needs, regulatory requirements and communication needs.

Intermediate computer skills including word processing, presentation applications and electronic mail.

Physical Requirements and Working Conditions:

Subject to exposure to chemical and hazardous waste and communicable disease; therefore protective clothing must be worn, as necessary.

Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties