Medical Social Worker

Naswtx; Houston (TX); On-site; USD 60,000 - 80,000; Full time

Job summary

Naswtx seeks a Medical Social Worker to support patients and families in adapting to medical diagnoses within a fast-paced setting. You will assess needs, plan care, and coordinate with the interdisciplinary team to achieve safe discharges and access to community resources.

The role emphasizes psychosocial assessments, care coordination, and resource navigation, including end-of-life discussions and safety planning. A licensed social worker with relevant credentials is required.

Qualifications

• Master's degree in social work required.
• LMSW or LCSW license required by the TBHEC.

Responsibilities

• Conducts a psychosocial assessment and reassesses the plan of care with documentation.
• Screens for depression and suicidal ideation and coordinates referrals as needed.
• Communicates recommendations with patient, family and the interdisciplinary team.
• Develops an action plan with the patient and family, considering social, emotional, and environmental factors.
• Supports end-of-life decision making and coordinates with resources and teams.
• Engages patient, family and caregivers in problem solving and health care decisions.
• Evaluates and selects community resources based on psychosocial needs and provides referrals.
• Provides case management for psychosocial continuity of care.
• Completes maltreatment assessments and contacts protective services as appropriate.
• Facilitates timely discharge by participating in meetings and rounds.
• Collaborates with care coordination and outpatient teams to ensure continuity of care.
• Provides transition services for patients with chronic conditions and advance directives.
• Uses quality improvement processes to identify opportunities for program improvement.

Skills

Psychosocial assessment

Interdisciplinary collaboration

Patient counseling

Care coordination

Education

Master's degree in Social Work

Job description

We are searching for a Medical Social Worker, someone who works well in a fast-paced setting. In this position, you’ll assist patients and their families or caregivers in making psychosocial adaptations specific to their medical diagnosis, while facilitating eligibility determination for social programs and funding resources. Apply optimal utilization of health care services and community resources in accordance with the principles of human growth and development. You'll assess, plan, implement, deliver, monitor and evaluate the options and services required to address a patient's individualized plan of care in collaboration with the interdisciplinary team to achieve discharge goals.

Think you’ve got what it takes?

Job Duties & Responsibilities

• Conducts a psychosocial assessment, evaluating patient/family psychosocial risk factors and reassessing the patient’s plan of care, adjusting goals and interventions as needed as evidenced by documentation in the medical record and/or team observation/feedback
• Screens for depression and suicidal ideation, completes a mental health assessment as needed and takes appropriate steps based on outcome including referral to psychiatry services, mental health facility, court order for involuntary commitment, safety plan or referral to community resources
• Communicates recommendations with the patient, family and team to support a collaborative family centered approach and ensures effective communication through patient handoffs with interdisciplinary team as evidenced by documentation in the medical record and/or team observation/feedback
• Develops an action plan with the patient, caregiver or family and team taking into consideration variables that impact the patient’s plan of care including social, emotional, physical or environmental factors as evidenced by documentation in the medical record and/or team observation/feedback
• Supports patient/family or caregiver with resources related to end-of-life decision making and provides support for complex family dynamics, assessing for barriers to care and discharge and intervening to de-escalate non-productive behavior as evidenced by documentation in the medical record and/or team observation/feedback
• Engages and empowers patient/family or caregivers in problem solving anddecision-makingg regarding health care decisions as evidenced by documentation in the medical record and/or team observation/feedback
• Evaluates and selects appropriate community resources based on psychosocial assessment and supports referrals, independently assessing need for gap resources and making additional recommendations as evidenced by documentation in the medical record and/or team observation/feedback
• Provides case management for psychosocial continuity of care as evidenced by documentation in the medical record and/or team observation/feedback
• Completes maltreatment assessment and provides intervention in cases involving abuse or neglect and contacts protective services as appropriate and in accordance with state law as evidenced by documentation in the medical record and/or team observation/feedback
• Facilitates timely discharge by participating in team meetings, family meetings and unit rounds to address social, emotional, physical and environmental barriers as evidenced by attendance records and/or team observation/feedback
• Collaborates with care coordination and outpatient professionals to ensure patients and families receive necessary information, resources and continuity of care
• Provides transition services for patients with chronic conditions including education, resource identification, preparation for adult living skills and assistance with advance directives
• Utilizes quality improvement processes to identify opportunities for improvement, evaluate programs and measure outcomes as evidenced by leadership observation
• Participates in performance improvement initiatives and supports patient safety and satisfaction efforts as evidenced by leadership observation
• Pursues professional development through continuing education, implements changes, provides mentorship and serves as a resource to interdisciplinary team members regarding medical and legal reporting guidelines

Skills & Requirements

• Master's Degree Social Work required
• LMSW - Licensed Master Social Worker by the Texas Behavioral Health Ex Council (TBHEC) or LCSW - Lic Clinical Social Worker by the Texas Behavioral Health Ex Council (TBHEC) required