The Social Worker works in collaboration with a multidisciplinary team by identifying and initiating discharge planning to accomplish the timely transition of patients to a post-acute hospital setting and to ensure patients progress along the continuum of care. The Integration of social services into medical care facilitates patient transitions efficiently and in a cost-effective manner that ensures quality outcomes. The social worker must understand social determinants of health and how they impact patient outcomes. The social worker must have an in-depth knowledge of community resources and ability to navigate systems related to health and human services, social security, and other referral agencies. They are responsible for communicating with external agencies to provide referral information for a smooth transition from hospital to the post-hospital setting. This includes communicating with other health care agencies and payer sources. The social worker will provide assistance to patients, families and others with a wide variety of needs to include, but not limited to, discharge planning, financial concerns and/or emotional problems related to the current acute illness. Provides supportive counseling to patients regarding adjustments to illness as well as other psychosocial needs as indicated.

Essential Functions and Responsibilities

1. Accurately assesses psychosocial situations at the appropriate level and develops a treatment plan consistent with identified needs.

2. Implements safe discharge/treatment plans in a timely manner to prevent avoidable inpatient stays.

3. Explores options with patient/family and appropriately assists in the decision-making process.

4. Communicates discharge planning activities with interdisciplinary team daily through the maintenance of concurrent documentation and/or verbal report.

5. Demonstrates a current working knowledge of community resources, eligibility criteria and referral processes.

6. Refers cases to home health, hospice, skilled nursing care facilities, DME companies, and other OP services and provides concurrent information as required.

7. Assures response to and documentation of received referrals/consultation within 24 working hours.

8. Knows a variety of social theories and is skilled at applying them in clinical practice setting based on accurate assessment of patient needs.

9. Demonstrates self-awareness as it relates to theory and practice; successfully overcomes personal biases to objectively provide services.

10. Supports patients/families/staff without colluding with dysfunctional behaviors.

11. Is a patient advocate.

12. Effectively organizes and sets priorities on assignment caseload.

13. Knowledgeable of Medicare, Medicaid, and non-governmental payer regulations for patient care requirements.

14. Identifies community resources and maintains working relationships with referral agencies.

15. Demonstrates service excellence by following HIPAA guidelines and meeting the Conditions of Participation set forth by the Center of Medicare and Medicaid Services (CMS).

16. Serves as a resource to the healthcare team.

17. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner.

18. Helps to identify problems, offer solutions, and participates in their resolution.

19. Demonstrates self-directed learning.

20. Maintains the confidentiality of information acquired pertaining to patients, physicians, employees, and visitors to Trinity Health facilities. Discusses patient and hospital information only among appropriate personnel in appropriately private places.

21. Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.

22. Maintains a working knowledge of applicable Federal, State and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical and professional behavior.

23. Attends team huddles and meetings when working; if unable to attend then review of notes/minutes from meetings is required. Staff are accountable for knowing content of discussions.

OTHER FUNCTIONS AND RESPONSIBILITIES

Performs other duties as assigned.

Professional Development

All MSWs are expected to engage in professional role activities, including leadership, appropriate to their education and position. MSWs are accountable for their professional actions to themselves, their healthcare consumers, their peers and to society. MSW abides by the NASW code of ethics is recognized as an expert in professional practice. The Social Work Case Manager is expected to contribute to the professional growth of others by acting as a preceptor, coach, and mentor.

Required Education, Experience and Certification/Licensure

A. Licensure/Certification/Registration: Current MSW degree required; LMSW preferred. BLS required.

B. Education: Must be a graduated of a Master of Social Worker program.

C. Experience: Minimum of 3 years' experience in social work; hospital case management preferred.

Our Commitment to Diversity and Inclusion
 

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.