Social Work Consultant, Emory Saint Joseph, Part Time

Job Summary

Discharge Planning:
The primary role of the Medical Social Worker II for hospital settings is to facilitate the execution of approved and appropriate inpatient discharge plans between facilities or into the community. Under the general direction of the Continuum of Care Leader and via clear and consistent communication with the onsite care management staff, the Social Worker delivers age‑appropriate clinical social work insight and care to members and their caregivers in accordance with agency policy and procedure and state and federal regulations.

The Social Worker serves as an integral member of the healthcare team, ensuring coordination of discharge/transition planning and providing referrals to internal resources within the Kaiser Permanente network, information to community resources and other social work services to meet the complex needs of patients and families transitioning from hospital settings.

• Responsible for overseeing or participating in individual discharge plans which assist members and families to transition to the appropriate level of care upon completion of the acute treatment plan.
• Partners with multidisciplinary teams to identify needs and collaborate on executing individual discharge plans.
• Discusses options for care proactively, including Kaiser resources and external community/government resources to assist members and caregivers in developing short‑ and long‑term care plans.
• Collaborates with other disciplines in assessing, planning, and providing services for patients utilizing biopsychosocial information.
• Coaches members pre‑discharge in advocating for self to receive appropriate services within Kaiser and in the community.
• Ensures members and caregivers are updated with approved discharge plans.
• Takes, reviews, evaluates, and prioritizes written and oral referrals.
• Maintains documentation, records, and data collections.
• Completes required documents in a complete and timely manner.
• Functions as a liaison to the Post‑Acute Team to assure appropriate, timely placement of Kaiser members in facilities.
• Serves as a liaison between patient and Kaiser, maintaining a positive relationship with Kaiser and ensuring continuity of care.
• Identifies appropriate levels of care and facilities for referred patients when applicable.
• Obtains placements, where applicable.
• Collaborates with internal and external resources in Kaiser and the community to meet mutually agreed‑upon goals and objectives.
• Provides information and referral to community resources as requested.
• Coordinates exchange of information among Kaiser, families, members, and all facilities involved in the discharge plan.
• Determines application of Kaiser, Medicare, and any additional insurer benefits to specific patient situations.
• Coordinates the application of all active insurance coverage for the purposes of care transitions and ensures that coverage benefit coordination is communicated to all facilities involved.
• Participates in utilization management/quality assurance activities.
• Assists in coordinating communication between regional offices, clinics, hospitals, and field staff.
• Remains knowledgeable of contract benefits and current, relevant state and federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management.
• Works cross‑functionally with other departments to strive toward organizational goals and objectives.
• Works with referral sources to clarify and complete required clinical and psychosocial information.
• Provides consulting services to the local Kaiser Permanente Acute Care Centers, Clinical Decision Units, and core hospital KP partners on occasion.
• Escalates issues and barriers timely and appropriately.
• Performs other related duties as necessary.

Minimum two (2) years of social work experience identifying and managing discharge and psychosocial needs of inpatients in an acute care or managed care setting within the last five (5) years.

• Minimum two (2) years of social work experience identifying and managing discharge and psychosocial needs of inpatients in an acute care or managed care setting within the…