Overview This incumbent provides a wide range of clinical social work services and interventions to assist individuals, and families to restore, improve, or protect their capacity for productive social functioning and coping with the consequences of their illness and health care status. The individual is able to assume independent practice and takes a leadership role in patient care, program and professional issues that they confront in their daily practice. The care coordinator assesses the patient’s plan of care and develops, implements, monitors and documents the utilization of resources and progress of the patient through their care, facilitating options and services to meet the patient’s health care needs. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This position is accountable for the quality of clinical services delivered by both them and others and identifies/resolves barriers which may hinder effective patient care. This position has responsibility to determine how to best accomplish functions within established procedures, consulting with leader on any unusual situations. Internal customers include all levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External customers include physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies. This position is a casual at Woodwinds Hospital. MSW LICSW encouraged to apply! Responsibilities Job Description The Social Worker, BSW or MSW is responsible to identify and create action plans to meet the social, psychosocial, environmental and/or discharge planning needs of patients and families. The social worker assists patients and families in maximizing the utilization of health care and community resources in order to achieve their optimallevel of wellness. Assesses patient situation and identifies patient care and discharge needs: Performs psychosocial assessment on high risk and referred patients to determine psychosocial and discharge planning needs Assesses family/social support Works with other interdisciplinary team members to assess patient's functional capacity, need for community services or placement to meet identified care needs Assesses cognitive and coping abilities of patient/caregivers and ability to carry out plan Analyzes assessment and medical data to prioritize needs and determine priority problem(s) Documents assessments and interventions on interdisciplinary care plan and medical record Acquires input from patient and family caregivers regarding their needs and desires Assures that assessments, interventions and teaching plans reflect the developmental level needs of patient/family Develops and facilitates timely individualized patient care and discharge plans: Attends interdisciplinary team meetings and collaborates regularly with team Arranges and mobilizes a range of community resources to meet identified patient/family needs Formulates plan, communicates and educates patient/caregivers and referral sources about plan details to assure common understanding and agreement with plan; evaluates efficiency of learning Modifies plan based on patient's evolving needs and wishes Collaborates with agencies and case managers already involved in patient's care Documents evolving assessments and plans Provides a range of generalist social work interventions to assist patients and families reach their goals: Facilitates case management, crisis intervention, problem solving, supportive counseling, group work, psycho education, information and referral services, and abuse reporting as appropriate Identifies rapidly changing situations and intervenes to prevent or resolve a crisis, increased length of hospital stay or unnecessary hospital admission Identifies mental health issues and refers to appropriate provider for intervention and follow-up Provides information and referral to community members and ambulatory care settings and maintains community resource file Advocates for individual patients, families and patient groups from social work theory and practice perspectives: Educates health care team members regarding social work role Educates health care team members and community on pertinent patient care issues, community resources, financial impact issues, patient rights and population specific information Serves as patient advocate and liaison with physician, interdisciplinary team and community services/agencies to ensure continuity of care and to meet patient needs Provides macro social work intervention to health care system by identifying barriers/issues related to providing patient care Participates in quality improvement processes to improve services to patients/families Seeks to advance the field of social work: Promotes ethical social work practice as defined by the licensing and professional organizations that supervise the profession Serves as preceptor or field instructor for social work undergraduates and new employees. (not applicable to home care) Serves entity committees as appropriate Engages in clinical supervision as defined by the entity Qualifications Required: Bachelor’s Degree or Master’s Degree in Social Work Current MN Social Work Licensure Excellent written and verbal communication skills Excellent critical thinking and problem-solving ability Good interpersonal skills Knowledge of and ability to communicate with diverse patient populations Time Management skills Excellent teamwork ability Knowledge of systems thinking Basic PC skills Understanding of unit and hospital-specific documentation procedures. Preferred: More than one year medical Social Work experience EEO Statement EEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status