Care Transitions Social Worker

GENERAL SUMMARY

The Care Management Social Worker collaborates with health care team members to identify and plan for the complex psychosocial needs of patients and families. The role assists patients and families in adjusting to the demands of chronic health care needs across the continuum, serves as a resource to the inter‑disciplinary team, and provides support and case consultation to other case‑management team members when complex issues arise.

• Commits to the mission, vision, beliefs and consistently demonstrates our core values.
• Completes case management assessments; determines priorities for case management intervention and differential treatment needs of patients and families; documents assessment, plans and interventions based upon departmental standards.
• Utilizes knowledge of high‑risk indicators to identify all forms of family violence; understands impact of different types of chronic illness on the patient and family.
• Provides supportive counseling to patients and families to enhance coping mechanisms.
• Provides crisis intervention services to patients, families and staff; assists patients, families and staff in problem solving and conflict resolution.
• Serves as a resource to the inter‑disciplinary team and Care Management Discharge Specialists in meeting complex needs of patients and families throughout the process of discharge planning.
• Partners with Care Management Discharge Planning staff to assist in identification and resolution of complex and problematic discharge planning issues.
• Maintains professional relationships and communicates effectively with other members of the inter‑disciplinary team.
• Initiates communication with peers about clinical practice issues.

Masters degree in Social Work (MSW) from a School of Social Work or Masters degree in Counseling required. Current certification as a Licensed Mental Health Practitioner (LMHP) by the State of Nebraska preferred. Prior case management experience desired.