Job Description

Job Description

Beyond outstanding benefits, competitive salaries, and health and dental insurance, we take pride in hiring the best, most passionate employees. Our talented staff reflects the culturally and ethnically diverse community we serve. They are proof of our commitment to creating a dynamic, inclusive environment that fuels innovation and the gold standard of patient care we strive for.

What will you be doing in this role?

The Clinical Social Worker, MSW is responsible for the development, planning, implementation, and evaluation of all social service-related interventions for corresponding Department/s. He/she is responsible for identifying patients who have psycho/social needs on an inpatient or outpatient basis, developing patient care goals and treatment plans as agreed upon by the patient's care team, and being available to physicians and nurse case managers as a consultant for patients with complex psychosocial needs and advance care planning.

Responsibilities

• Evaluates and implements social service programs for patients with psycho/social issues focusing on seniors, catastrophic, and chronically ill patients.
• Develops social service documentation tools/templates in EMR for Social Work consults, family counseling, and group sessions, and IS reports for outcome measurements.
• Performs triage for patients within corresponding team(s) and assists in coordinating patient care delivery, including DPA/POSLT, and documents pertinent information in the case management system.
• Implements transitions of care between inpatient and continued outpatient follow-up and vice versa.
• Initiates team care conferences to include patient, family, and care providers.
• Evaluates daily caseload and assesses achievement of long- and short-term goals; modifies goals with providers and care team based upon patient outcomes.
• Compiles and presents statistics and reports relating to patient outcomes and documents findings in the patients EMR.
• Follows up on communication to the referral source, e.g., PCP, family member, case manager, home health personnel, community social worker, Health Plan, etc.
• Acts as the social services liaison for the department, particularly in the areas of: Advance Care Planning discussions, Complex discharge planning, Biopsychosocial assessments.
• Refers patients to agencies that provide supportive services optimizing patients' health plan benefits.
• Assists in arranging community resources (i.e., meals on wheels, transportation services, adult day care, and info-line) and in long-term planning for patients transitioning to an institutional setting.
• Acts as the liaison to the Population Health department regarding chronic disease state management programs.
• Participates in advance care planning initiatives.

Qualifications

Education:

• Master’s Degree in Social Work from a school accredited by the Council on Social Work Education.

Experience:

• 2 years of clinical social work experience including palliative or hospice care and discharge planning, with experience in project management preferred.

License:

• CA LCSW preferred.

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