Major Responsibilities
- Complete initial evaluation and place in medical record according to department policy.
- Collaborate with physicians and other hospital disciplines to proactively develop plans for continued care after discharge.
- Collaborate and coordinate with physicians, HMO, PPO, case managers, physical therapy, nursing and other personnel regarding discharge needs.
- Develop and update the discharge plan and document the plan in the medical record according to departmental policy.
- Act as community liaison to arrange resources and enhance safe and timely discharges.
- Organize and attend patient care conferences to further identify each patient’s potential discharge needs.
- Establish and maintain positive working relationships with all referral sources.
Discharge Planning for Hospital Inpatients
- Assess patients for discharge planning needs.
- Complete initial evaluation and place in medical record according to department policy.
- Collaborate with physicians and other hospital disciplines to proactively develop plans for continued care after discharge.
- Collaborate and coordinate with physicians, HMO, PPO, case managers, physical therapy, nursing and other personnel regarding discharge needs.
- Develop and update the discharge plan and document the plan in the medical record according to departmental policy.
- Act as community liaison to arrange resources and enhance safe and timely discharges.
- Organize and attend patient care conferences to further identify each patient’s potential discharge needs.
- Establish and maintain positive working relationships with all referral sources.
Provision of Counseling Services to Patients and Families
- Utilize crisis intervention techniques when indicated.
- Evaluate patient/family support systems, financial support, and lifestyles.
- Provide adjustment counseling with emphasis on education/support.
- Provide information regarding community resources for ongoing counseling services.
- Provide age specific appropriate assessment and counseling for patients and family support systems.
Timely and Complete Documentation to Meet Licensure and Third‑Party Payor Requirements
- Documentation of assessment and/or plan entered in the medical record, adhering to hospital policy.
- Documentation reflects accurate psychosocial assessment, case progress, and plan of action.
Provision of In‑services to Assigned Units and Attendance of Educational Seminars as Appropriate
- Continuing education is a professional responsibility.
- Continuing education units (CEU’s) required for licensure will be completed and documented within NASW timeframes.
- Conduct in‑services on assigned units as indicated and appropriate.
- Conduct support groups as assigned.
- Provide patient, family, and significant other education as needs are identified.
Preparation of Statistical Records
- Conduct monthly audits and enter data as per department policy.
Functions as a Member of the Care Management Team
- Attends patient care conferences and multi‑disciplinary team conferences.
- Keeps staff informed of social work progress on open cases and notifies appropriate personnel of updates and changes.
- Collaborates with members of the health care team as indicated.
- Evaluates the patient/family’s psychosocial needs in relation to the medical situation.
- Continuously collaborates with the assigned case manager.
- Prioritizes referrals.
Contributes to Continuous Process Improvement Activities
- Offers innovative ideas to improve the efficiency and effectiveness of the department.
- Collects data as requested by department head.
Licensure and Credentials
Social Worker, Clinical Education/Experience Required: MSW from an accredited school of Social Work and field experience within a hospital setting. Must adhere to NASW code of ethics and standards.
Knowledge, Skills & Abilities
Demonstrates competence in counseling and discharge planning. MSW (Licensed Social Worker) required.
Physical Requirements and Working Conditions
Inevitable lifting requirement: Ability to lift up to 35 pounds without assistance. For lifts over 35 pounds, patient handling equipment and at least one additional staff member are expected to be used when available.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.