CD Patient Care - Continuing Care - SW

Kaiser Permanente; Wailuku (HI); On-site; USD 54,000 - 68,000; Full time

Job summary

Kaiser Permanente Maui Memorial is seeking a social worker to provide psychosocial assessments, discharge planning, and care coordination for patients and families. The role serves as a liaison between Maui Health System and community agencies to integrate services and improve outcomes.

Responsibilities include crisis intervention, family meetings, resource navigation, and advocacy for patient rights, while ensuring CMS and HIPAA compliance and contributing to interdisciplinary rounds.

Qualifications

• Healthcare experience in social work settings.
• Ability to network with community agencies and resources.
• Strong communication and interpersonal skills.

Responsibilities

• Conduct psychosocial assessments to identify patient and family needs related to hospitalization and discharge planning.
• Develop and implement social work service plans focused on resource needs and care transitions.
• Coordinate discharge planning and care transitions, including referrals to appropriate providers.
• Manage socially complex cases involving barriers to discharge such as homelessness or guardianship.
• Collaborate with community agencies and legal resources to address social determinants of health.
• Provide crisis intervention and emotional support during medical events or end-of-life situations.
• Facilitate family meetings to clarify goals of care and address psychosocial concerns.
• Perform case management and resource navigation, including financial assistance and transportation.
• Advocate for patient rights and assist with advance directives.
• Ensure CMS and HIPAA compliance; participate in rounds and care conferences.
• Provide culturally competent care and respect diversity.
• Document per departmental standards and participate in performance improvement.
• Attend departmental meetings and assist with orientation of new personnel.

Skills

Healthcare experience

Community agency networking

Communication skills

Education

Bachelor's Degree in Social Work with 2 years healthcare experience

Master's Degree in Social Work

Job description

Job Summary

Provides social work services, including psychosocial assessment, discharge planning, care coordination, and resource navigation for patients and their families. Collaborates with the interdisciplinary team to ensure safe transitions of care and addresses psychosocial needs during hospitalization. Serves as liaison between Maui Health System (MHS) and community agencies to integrate services and enhance patient outcomes.

• Conduct psychosocial assessments to identify patient and family needs related to hospitalization, discharge planning, and community resources.
• Develop and implement social work service plans focused on resource needs, support systems, and care transitions.
• Coordinate discharge planning and care transitions, including referrals to appropriate providers, to ensure safe and timely discharge to home or post-acute care settings.
• Manage socially complex cases involving barriers to discharge such as homelessness, behavioral health concerns, substance use, guardianship, abuse/neglect, or lack of caregiver support.
• Collaborate with community agencies and legal resources to address complex social determinants of health and ensure safe discharge planning.
• Provide crisis intervention and emotional support for patients and families during acute medical events, trauma, or end-of-life situations.
• Facilitate family meetings to clarify goals of care and address psychosocial concerns.
• Perform case management and resource navigation, including financial assistance, insurance benefits, transportation, and community programs.
• Advocate for patient rights and assist with advance directives and healthcare decision-making support.
• Ensure compliance with CMS Conditions of Participation for discharge planning and maintain HIPAA standards for confidentiality.
• Participate in interdisciplinary rounds and care conferences to communicate patient needs and advocate for appropriate services.
• Provide culturally competent care, respecting diversity and incorporating cultural values and family-centered practices.
• Document according to departmental standards and regulatory requirements to assure compliance and continuity of care.
• Participate in performance improvement activities, maintain educational records, and demonstrate competency.
• Attend departmental meetings, in-services, and assist with orientation of new personnel as assigned.

Job Summary

Provides social work services, including psychosocial assessment, discharge planning, care coordination, and resource navigation for patients and their families. Collaborates with the interdisciplinary team to ensure safe transitions of care and addresses psychosocial needs during hospitalization. Serves as liaison between Maui Health System (MHS) and community agencies to integrate services and enhance patient outcomes.

• Conduct psychosocial assessments to identify patient and family needs related to hospitalization, discharge planning, and community resources.
• Develop and implement social work service plans focused on resource needs, support systems, and care transitions.
• Coordinate discharge planning and care transitions, including referrals to appropriate providers, to ensure safe and timely discharge to home or post-acute care settings.
• Manage socially complex cases involving barriers to discharge such as homelessness, behavioral health concerns, substance use, guardianship, abuse/neglect, or lack of caregiver support.
• Collaborate with community agencies and legal resources to address complex social determinants of health and ensure safe discharge planning.
• Provide crisis intervention and emotional support for patients and families during acute medical events, trauma, or end-of-life situations.
• Facilitate family meetings to clarify goals of care and address psychosocial concerns.
• Perform case management and resource navigation, including financial assistance, insurance benefits, transportation, and community programs.
• Advocate for patient rights and assist with advance directives and healthcare decision-making support.
• Ensure compliance with CMS Conditions of Participation for discharge planning and maintain HIPAA standards for confidentiality.
• Participate in interdisciplinary rounds and care conferences to communicate patient needs and advocate for appropriate services.
• Provide culturally competent care, respecting diversity and incorporating cultural values and family-centered practices.
• Document according to departmental standards and regulatory requirements to assure compliance and continuity of care.
• Participate in performance improvement activities, maintain educational records, and demonstrate competency.
• Attend departmental meetings, in-services, and assist with orientation of new personnel as assigned.

Experience

Basic Qualifications

• N/A

Education

• Bachelors Degree in Social Work and two (2) years of social work experience in healthcare setting OR Masters Degree in Social Work.

License, Certification, Registration

• Licensed Bachelor Social Worker (Hawaii) OR Licensed Clinical Social Worker (Hawaii) OR Licensed Social Worker (Hawaii)
• Basic Life Support required at hire from American Heart Association

Additional Requirements

• Healthcare experience working with medical diagnoses.
• Demonstrated ability in networking with community agencies.

Preferred Qualifications

• Minimum one (1) year of social work experience.
• Certified Case Manager (CCM) or Accredited Case Manager (ACM) Certification.

Primary Location: Hawaii,Wailuku,Maui Memorial - Molokini II

Scheduled Weekly Hours: 1

Shift: Day

Workdays: Mon, Tue, Wed, Thu, Fri, Sat, Sun

Working Hours Start: 08:00 AM

Working Hours End: 04:30 PM

Job Schedule: Call-in/On-Call

Job Type: Standard

Worker Location: Onsite

Employee Status: Regular

Employee Group/Union Affiliation: S03|AFSCME|UNAC-UHCP-UNHCEH

Job Level: Individual Contributor

Department: MAUI MEMORIAL MEDICAL CENTER - UR-Case Mgmt - 3601

Pay Range: $39.39 - $49.25 / hour

Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data, internal alignment, and a candidate's years of relevant work experience, education, certifications, skills, and geographic location.

Travel: No

Work Setting: Onsite

Worker location must align with Kaiser Permanente's Authorized States policy.

Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.