Clin Care Social Worker

Overview

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This position comprehensively plans for the coordination of care for the WVU Medicine patient population across the continuum. Performs psychosocial assessments, crisis intervention, resource management, discharge planning, care facilitation, and referrals to alternate levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes. The position intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies.

In addition, may offer crisis intervention to patients and families with psychosocial needs and collaborates with the patient care team in the development of a transition/discharge plan of care for all patients.

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• Masters degree in Social Work
• Current social worker licensure as required by the state where work is being performed.
• WV:
  Licensed Graduate Social Worker (LGSW), Licensed Certified Social Worker (LCSW) or Licensed Independent Social Worker (LICSW) through the West Virginia Board of Social Work
• MD:
  Licensed Masters Social Worker (LMSW) or Licensed Certified Social Worker – Clinical (LCSW-C) through the Maryland Board of Social Work

Preferred Qualifications
:

• One to three years of experience preferred

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

• Manages all aspects of transition/discharge planning for assigned patients in a timely manner using escalation processes as needed when barriers encountered.
• Collaborates with all members of the multidisciplinary team to facilitate the transition/discharge process for designated caseload
• Monitors the patient’s progress; intervening as necessary to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective
• Maintains extensive knowledge of federal, state, and local assistance programs and community resources that affect patient needs
• Demonstrates professional practice with respect for confidentiality and freedom of choice as outlined by the NASW Code of Ethics and state regulations
• Provides education as needed to staff, physicians, and patients and their families to ensure effective transition planning
• Meets directly with the patient and/or family to assess needs and develop an individualized transition/discharge plan in collaboration with the physician team
• Provides social work assessment and interventions for complex crisis including but not limited to mental health, substance abuse, adjustment to health status and grief/loss situations
• Communicates with the multidisciplinary team and post-acute providers regarding complex family dynamics affecting care and transition planning
• Initiates and facilitates referrals to post-acute services (e.g., Homecare, DME, Hospice, LTAC, Acute Rehab, SNF)
• Communicates transition/discharge plan details to the team, patient, and family; assists in understanding patient reactions to illness and environmental factors
• Provides timely documentation of interactions and progress per regulatory policies
• Knowledge of current medical insurance coverage and precertification requirements for DME and post-acute placements
• Assists patient/families with completion of medical power of attorney, health care surrogate, and advanced directives
• Utilizes clinical skills to provide assessment and intervention for complex abuse, neglect, foster care, homelessness, domestic…