Social Worker II - MSW - CareVio - M-F - Dayshift

PRIMARY FUNCTION:

To work as a team member of an ambulatory complex care and assist with program development and decision making on merging service delivery and program access issues. To assist patients and families to identify health, social, emotional, and environmental needs and to connect them with available resources/services through the provision of a full spectrum of longitudinal health and social work services.

Participates as a member of a team, focused on addressing and improving the behavioral, physical and mental health of a focused segment of the population. Merging all aspects of health into a longitudinal, sustainable solution for health self-management.

Understands and leverages multiple electronic systems including population health platform(s), electronic medical records, health information networks, state and federal agencies sites.

Provides information on social service programs and state and federal regulations specific to the specialty population.

Works with the patient, family, community, state and federal agencies, inpatient facilities and any other applicable resources to formulate a plan for longitudinal support (whether related to a hospital admission, or in the community) and self‑management of behavioral, physical and social health conditions. Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources.

Employs assessment to develop a comprehensive case management plan that will address the needs identified. Determines specific objectives, goals, and measures that are designed to meet the client’s needs that have been identified through comprehensive assessment.

Provides information about resources and options available in the community and coordinates service delivery.

Interprets patient/family needs and provides information concerning the availability and limitations of resources.

Educates and addresses concerns with service delivery including service gaps and access issues. Links patient/family with available community and government resources to meet their identified needs. The social worker always assures the patient is given the choice regarding agencies and services. Assists the patient and family in all aspects of accessing resources including in‑person accompaniment, assistance with forms, advocating with agencies on their behalf, working with other facilities on support planning.

When inpatient or in the emergency department, coordinates with members of the health care team to formulate a discharge plan that provides the patient services in the appropriate post‑acute care setting. The plan will be action‑oriented and time‑specific including collaboration with utilization management to manage length of stay. As part of the discharge plan development process, collaborates with other healthcare professionals in case review.

Screens all clients for their need and desire for social work services. May screen and assist others in the family unit, as needed. Consults with medical providers, behavioral health providers, ancillary services, psychiatric facilities, hospital facilities, all pertinent social service providers, legal system and other partners as needed to identify and implement care systems for the client for needs as determined by assessment and client preference.

Participates in outpatient multidisciplinary case reviews, focused on patient panel and patients of other team members.

Provides factual information based on current knowledge of their specialty service, to provide psychosocial support and assist the patient/family in coping with their disease to improve their overall health care management.

Provides specific information on how to communicate with physicians and other medical, social service, legal or other staff to better utilize the resources and increase understanding of the process.

Establishes comprehensive care plans for those patients with longitudinal care needs in accordance with established clinical guidelines, standards, and pathways. Organizes, secures, integrates and modifies the…