Social Worker- Full Time, Day

SUMMARY

As a Social Worker, you play an important and trusted role in the lives of patients and their family. You are an integral part of their care and recovery.

POSITION: Social Worker              

LOCATION: Wegman Family Cottages - PRLC   

DEPARTMENT: Transition Care Center     

SCHEDULE: Monday-Friday 7:30am-4pm

HOURS: Full time 40 per week

ATTRIBUTES

• One (1) year of experience in a healthcare setting preferred
• Compassionate, warm and patient focused
• Exceptional documentation and planning skills
• Excellent communication and interpersonal skills

RESPONSIBILITIES

• Patient Care. Determine patient needs through rounds, chart review, patient/family interviews and team conferences; coordinate multidisciplinary and agency case conferences; work with care managers to advocate for patient/family to obtain approval for insurance coverage
• Referral Management. Manage referrals related to patients at risk and determine appropriate intervention strategies and document as implemented; ensure inappropriate referrals are channeled correctly and documented
• Treatment Plan Development. Coordinate assessments and develop care plan in accordance with accepted social work policy; implement plan of intervention preparatory to discharge or initiate continued care plan

Key Responsibilities:
•  Manages referrals related to patients with psychosocial needs and determines appropriate interventions and strategies to meet those needs. Reviews track board census or documentation to identify high risk patients not referred.  Determines patient needs through interdisciplinary rounds, chart review, patient/family interviews and team conferences.  Documents social work intervention.  Ensures that all inappropriate referrals are channeled correctly and documented.
•  Assesses patient needs and determines mode of intervention.  Possesses appropriate age and specific knowledge about the dynamics of group assigned and assesses patient needs accordingly as documented in Care Connect or medical record.  Interviews patients and/or families and records psychosocial assessments in accordance with the social work documentation policy as documented in chart.  Coordinates assessments and develops care plans in accordance with accepted social work policy as documented in chart.  If indicated, evaluates patients for the appropriate level of care as documented in chart, office file, and by referrals.  Coordinates multidisciplinary and agency case conferences as needed, as verified through chart notes indicating attendance, problems discussed and treatment plan.
•  Implements plan of intervention preparatory to discharge  or initiating continued care plan in compliance with departmental and governmental regulations.  
•  Works with care manager, acts as intermediary, with Health Care Insurance providers (ex. HMO’s, private insurance, Medicare), advocating for patient/family, to obtain approval for coverage as documented in the chart.  Involves patient/family in the treatment planning process as demonstrated in the chart notes, and signatures on the appropriate forms.
•  Executes plan of discharge/continued care which is mutually agreeable to patient/family.  Notifies involved parties (ex., doctor, family, patient, facility) concerning the discharge, within 24 hours of receipt of discharge authorization as documented in chart.  Requests needed paperwork from nursing/doctor other disciplines as documented in the chart.  
•  Arranges for transportation of patient where needed in accordance with hospital procedure, as documented in the chart.
•  Acts as liaison with the community and as a referral source.  
•  Performs other duties as assigned.

For ElderONE Housing Coordination, the responsibilities include: 
• Eliminate wasted beds days in the hospital and skilled nursing facility that are due to housing barriers.
• Build effective relationships in order to creates housing options for ElderONE that vary in length of stay (short term vs long term vs permanent) and in the services they provide.
• Coordinate with interdisciplinary teams, discharge planners and other RRH and non RRH partners to ensure well-coordinated and timely discharges/transitions into housing as needed.
• Assists participants with all aspects of establishing housing (tours, documentation and paperwork, finances (rent, deposits, rep payee if needed) 
• Has a good pulse on participa.nts at risk for homelessness and creates proactive mitigation plans that prevents the need to use skilled nursing or unnecessary higher levels of care.
• Works with contracted and non-contracted skilled nursing facilities to provide hous