Medical Social Worker - Care Coordination & Discharge

Naswtx; Houston (TX); Vor Ort; USD 60.000 - 80.000; Vollzeit

Zusammenfassung

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.

Qualifikationen

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

Aufgaben

• 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.

Kenntnisse

Psychosocial assessment

Interdisciplinary collaboration

Patient counseling

Care coordination

Ausbildung

Master's degree in Social Work

Jobbeschreibung

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.