Clinical care social worker

Position Summary

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Sign-On Bonus Eligible

• Comprehensively plan coordination of care for the WVU Medicine patient population across the continuum.
• Perform psychosocial assessments, crisis intervention, resource management, discharge planning, care facilitation, and referrals to alternate levels of care.
• Work collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes.
• Intervene 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.
• Offer crisis intervention to patients and families with psychosocial needs and collaborate with the patient care team in the development of a transition/discharge plan of care for all patients.
• Manage all aspects of transition/discharge planning for assigned patients in a timely manner using escalation processes as needed when barriers encountered.
• Collaborate with all members of the multidisciplinary team to facilitate the transition/discharge process for designated caseload.
• Monitor patient’s progress; intervene as necessary and appropriate, to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.
• Maintain extensive knowledge of federal, state, and local assistance programs and community resources that affect patient needs.
• Demonstrate appropriate professional practice, maintaining respect for confidentiality and freedom of choice as outlined by the Code of Ethics by the National Association of Social Workers as well as the State Board of Social Workers.
• Provide education as needed to staff, physicians, and patients and their families to ensure effective transition planning.
• Meet directly with the patient and/or family to assess needs and develop an individualized transition/discharge plan in collaboration with the physician team.
• Provide 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.
• Communicate with the multidisciplinary team and post‑acute providers when applicable, any complex family dynamics that may directly impact patient care and transition/discharge planning.
• Initiate and facilitate referrals to post‑acute services – including but not limited to homecare, durable medical equipment, hospice care, long term acute care facilities, acute rehab facilities, and skilled nursing facilities.
• Communicate all necessary information regarding transition/discharge plan to the multidisciplinary team, patient and family. Assist other team members to understand and appreciate a patient and/or family’s reaction to a serious illness and/or chronic illness/disease as well as to understand other environmental factors affecting care, treatment and compliance.
• Provide timely and comprehensive documentation of interactions with patient and/or families and all transition/discharge planning activities and progress according to regulatory policies and procedures.
• Have working knowledge of patient’s current medical insurance coverage and limitations and the precertification requirements for durable medical equipment, post‑acute placements, infusions, transfers, etc.
• Assist patient/families with completion of medical power of attorney, health care surrogate, and advanced directives.
• Utilize clinical skill and expertise to provide assessment, intervention, and where appropriate, reporting for complex abuse, neglect, foster care, adoption, mental health placement, homelessness, domestic violence, and sexual assault situations.
• Collaborate for appropriate resource and financial management which may include but is not limited to financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination.
• Communicate with the Care Management Resource Center and/or third‑party payors to facilitate covered day reimbursement certification for assigned patients and…