MSW- Abington Care Management

Jefferson Health; Abington Township (PA); On-site; USD 60,000 - 80,000; Full time

Job summary

Jefferson Health is seeking a hospital-based Social Worker to assess and enhance patients' coping abilities and coordinate discharge planning. You will collaborate with a multidisciplinary team to support patients and families through illness, discharge, and end-of-life care decisions.

You will provide psychosocial counseling, navigate community resources and insurance processes, and assist with planning for post-acute care and home/hospice arrangements where appropriate.

Qualifications

• Master’s Degree in Social Work from an accredited program required.
• 2 years hospital-based social work experience required.
• Knowledge of medical terminology, disease processes; community resources; insurance regulations and requirements.
• Ability to work with multidisciplinary teams, outside resources, patients/families/significant others.
• Ability to establish an appropriate plan to safely discharge patients to the next level of care.
• Provides counseling and crisis interventions; advocates for patients/families to obtain necessary services.

Responsibilities

• Interact with co-workers and staff in line with Jefferson values.
• Conduct psychosocial assessments related to illness and health maintenance needs.
• Develop and implement interventions addressing identified needs.
• Collaborate with multidisciplinary team to ensure discharge planning.
• Provide psychosocial counseling and crisis interventions to patients and families.
• Coordinate discharge plans and placement for post-acute care when needed.
• Educate patients/families about health insurance processes and welfare applications.

Skills

Counseling

Crisis intervention

Discharge planning

Case management

Multidisciplinary teamwork

Education

MSW (Master's in Social Work)

Tools

EMR systems

Job description

Provides social work services, assesses and enhances the patient's/family's/significant other's ability to cope with physical, emotional and environmental problems related to illness/convalescence and discharge plan. Works collaboratively with the multidisciplinary healthcare team to establish a discharge plan for the patient.**Job Description** **Summary** Provides social work services, assesses and enhances the patient's/family's/significant other's ability to cope with physical, emotional and environmental problems related to illness/convalescence and discharge plan. Works collaboratively with the multidisciplinary healthcare team to establish a discharge plan for the patient. **Job Duties*** Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.(Do not delete, move or over-write this statement)* Conducts psychosocial assessment/reassignment of patients/significant others relating to the social, emotional and cognitive capabilities of patients in relationship to their illness and health maintenance needs.* Develops and implements a plan of intervention that addresses identified needs related to needs/problems identified during assessment.Collaborated with the multidisciplinary team to ensure appropriate discharge planningProvides counseling for patient/family/significant others to assist with coping with new diagnoses, chronic illness and palliative or terminal care* Advocates on behalf of the patients/families to enable them to obtain necessary services. **Minimum Qualifications*** Master’s Degree Graduate from an accredited Masters of Social Work program required. Masters of Social Work required.* 2 years hospital based social work experience.* Knowledge of: Medical terminology and disease process; Community resources; Insurance regulations and requirements* Skill in: Work with multidisciplinary teams, outside resources, patients/families/significant others* Ability to: Establish an appropriate plan to safely discharge patients to the next level of care* Serves as a resource and provides counseling and intervention related to treatment decisions and end of life care issues.* Refers patient/significant other to community based services/resources to meet patient’s continuum of care needs.* Coordinates team and/or family conferences when necessary to facilitate patient’s care progression.* Provides psychosocial counseling and crisis interventions to patients/significant others with needs. Provides interventions in cases involving child abuse/neglect, domestic violence, elder abuse and institutional abuse. Provides intervention in cases involving guardianship, foster care, adoption, psychiatric assessment and placement, Advance Directives (Center City), trauma and substance abuse.* Facilitates completion of all placement related documentation in nursing home grants, applications, etc. Completes referrals to options programs where appropriate.* Documents in accordance with hospital and departmental requirements.* Works with Case Managers in providing discharge planning services per departmental policies and procedures in collaboration with the multidisciplinary team and patient/family.* Identifies patients and locates family and/or next of kin.* Educates patients/significant others on the process for obtaining health insurance. Provides appropriate documents/information to apply for welfare insurance.* When necessary, initiates medical assistance application in a timely manner (Center City) or ensure medical assistance application has been initiated by identified external agencies (excludes Center City). Follows up with identified external service regarding application.Provides psychosocial assessment and intervention as well as documents in the electronic medical record updates throughout patient’s hospitalization, discharge planning process and relevant post-acute care* Supervises field placement of MSW students.* When appropriate, refer case to the Placement Official Social Worker to assist in obtaining placement for the patient’s discharge (Center City and Abington/Lansdale).* Precept and mentor new staff members to their role and department.* Facilitates and coordinates discharge plans for patient identified to leave on the weekend, including homecare/hospice services; transportation; post-acute facility placements* Perform assessments and develops relevant interventions specifically for trauma patients (Abington)* Obtains relevant post-acute authorizations* Manages Livanta appeal determinations and if necessary address alternate discharge plans* Provides updates to post-acute facility liaisons regarding possible weekend discharges* Reviews discharge orders to determine which patients can be transitioned to the next level of care that day (JNE)* Assist with completing relevant 302 paperwork, when necessary* Documents updates for the week day staff per department procedures.