MSW Social Worker: Discharge & Care Coordination

Vanderbilt University Medical Center; Clarksville (TN); On-site; USD 52,000 - 75,000; Full time

Job summary

Vanderbilt Health in Tennessee is seeking a Social Worker to evaluate psychosocial needs of patients and coordinate discharge plans. The role acts as a liaison between the facility and external resources, facilitating timely discharge and post-acute plan follow-up.

The Social Worker will provide crisis intervention, assist the Resource Manager with patient movement across the continuum of care, and identify barriers to throughput while upholding regulatory requirements and quality initiatives.

Qualifications

• LIC-Licensed Master Social Worker - Tennessee.
• Master’s degree in Social Work.
• Minimum 1 year of relevant work experience.

Responsibilities

• Performs a comprehensive assessment of psychosocial needs of assigned patients.
• Assesses patients discharge needs and facilitates the provision of services necessary to meet identified needs.
• Evaluates suspected abuse and neglect referrals and makes official reports.
• Develops an individual plan of care for recurring patients to include education related to accessing healthcare services at the appropriate level of care.
• Provides education to the under-resources patient/family of potential and available resources.
• In collaboration with the interdisciplinary team, develops, implements, evaluates, revises as needed, a discharge plan to include identifies psychosocial and discharge needs.
• Documents professional recommendations, care coordination interventions, and case management activities to effectively communicate to all members of the health care team.
• Participates with the interdisciplinary team to ensure psychosocial and discharge needs are addressed.
• Acts as a liaison through effective and professional communications between and with physicians, patient/family, hospital staff, and outside agencies.
• Demonstrates knowledge of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives.
• Makes appropriate referrals, after collaboration with the Case Manager, to third party payer disease and case management programs for recurring patients and patients with chronic disease states.
• Facilitates patient throughput with an ongoing focus on quality outcomes and an efficient transition between levels of care.
• Tracks and trends barriers to care, makes recommendations and develops action plans to improve processes and systems.
• Provides psychosocial support to patients and families through crises intervention.
• Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered.
• Acts as an advocate for identified needs and makes appropriate referrals.
• Acts as a liaison between the facility and community resources to enhance community outreach coordination.
• Tracks and trends variances barriers related to access to care.
• Adheres to established policy and procedure and standard of care.

Skills

Crisis Intervention

Patient Evaluation

Patient Assessment

Clinical Counseling

Education

Master's

Job description

Vanderbilt Health in Tennessee is seeking a Social Worker to evaluate psychosocial needs of patients and coordinate discharge plans. The role acts as a liaison between the facility and external resources, facilitating timely discharge and post-acute plan follow-up.

The Social Worker will provide crisis intervention, assist the Resource Manager with patient movement across the continuum of care, and identify barriers to throughput while upholding regulatory requirements and quality initiatives.