Facility: Wellstar West Georgia Hospice

Job Summary: The Social Worker maintains a caseload of patients in multiple settings to provide psychosocial services and assist the patient/family with resources, information and services to benefit their adjustment to illness, hospitalization and recovery throughout the continuum of care. This includes age appropriate interventions for children, adolescents, adults, and older adults. The Social Worker assesses the patient's situation and initiates appropriate action to obtain available community resources. The Social Worker participates in the development of the plan of treatment, preparing clinical notes, participates in team conferences and in the discharge planning process. The Social Worker is responsible for attending and participating in staff meetings, in-services, special projects and continuing education. Core Responsibilities and Essential Functions: DIRECT PATIENT CARE Assesses, manages and facilitates meeting patients needs and carries a caseload of patients in multiple settings (home care, ALF, SNF, PCH, IPU, etc). Appropriately schedules and adjusts frequencies of visits as status indicates per physician order Develops and revises individual plan of care based on patient need and physician order Meets established productivity standards Completes bereavement assessments, calls, follow ups and facilitates bereavement support groups as needed/required. Seeks training, supervision or direction from leadership as needed Rotates on call for weekends and holidays as directed by leadership. COORDINATION OF SERVICES FOR EPISODE OF CARE Coordinates care and services with community, clinical supervisor, and other team members Perform other duties as assigned by Department Leadership Maintain communication with physician reporting any changes that may affect the patients recovery PATIENT / CAREGIVER EDUCATION Serves as patient educator to foster self care or caregiver support for the patient. Be aware and report concerns to authorities or agency leadership on any issues that affect patient or staff safety. Utilize both verbal and written tools to facilitate learning and promotion of independence during recovery. COMMUNICATION AND DOCUMENTATION Carries a caseload of patients and provides psychosocial services in multiple settings. Meets all regulatory standards for timelines and documents in the EMR within 24 hrs of care. Demonstrates knowledge and appropriate application of regulatory guidelines Participates in care team conferences with coworkers regarding patient needs, discharges, risks, etc. Responsible for checking voice mail box and secure messaging a minimum of twice daily. STAFF EDUCATION AND PROFESSIONAL DEVELOPMENT Responsible for attending continuing education and in-services as directed and needed Responsible for maintaining current knowledge of community and professional resources for age appropriate patients Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct. Required Minimum Education: Graduate with a Masters Degree in Social Work from an accredited school, Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated.Lic Master Social Worker GABasic Life Support or BLS - InstructorMaster Social WorkerAdditional License(s) and Certification(s):Required Minimum Experience: in health care, one year in area of specialty Required Minimum Skills: Independent and self directed, problem solving skills, strong organizational and time management skills. Strong assessment and clinical skills. Strong written and verbal communication skills. Ability to write and follow directions to patients house. Use of Windows based computer, utilizing home health patient software, email, internet, computer based learning modules, etc. Knowledge of home health operations, case management, community resources, reimbursement, law and regulatory processes.