Job Description

JOB SUMMARY:
Provide psychosocial assessment, individual and family counseling and support, care planning, case management, and community education, outreach and referral services to clients and their families and/or caregivers.

EDUCATIONAL REQUIREMENTS
Bachelor's Degree in Social Work within 6 months.

CERTIFICATION & LICENSURE REQUIREMENTS
Licensed Social Worker (LSW) Illinois required at the time eligibility requirements are met or within 3 years of hire. within 3 years.

EXPERIENCE REQUIREMENTS
1 year of experience in/within medical setting.

SKILLS AND KNOWLEDGE
Required English Skills Advanced reading skills Advanced writing skills Advanced oral skills Communication Skills Ability to respond appropriately to customer/co-worker Interaction with a wide variety of people Maintain confidential information Ability to communicate only the facts to recipients or to decline to reveal information Ability to project a professional, friendly, helpful demeanor Computer Skills Basic computer knowledge: Uses word processing, spreadsheet, e-mail application, and web browser. Comfortable within a Windows OS and learning new applications. Outlook Patient Care related applications.

ESSENTIAL FUNCTIONS:

• Works collaboratively with Case Management and the care team to evaluate psychosocial needs and to develop timely and patient-centered discharge plans.* Key focus - low- and moderate-risk patients.* Demonstrates the knowledge and skills necessary to provide interventions that are appropriate and individualized to the patients' needs.* Demonstrates skills necessary to assess patients' needs for continuum of care issues and effective transition from hospital for both patient and his/her support system.* Participates in multidisciplinary rounding process as requested.* Exercises a substantial degree of professional judgment, recognizing deviation from the usual patient/family functioning, anticipating problems, and taking measures to maximize patient's successful discharge.* Assists with assessments of discharge needs for new patients, as well as assessment and problem-resolution for patients who return to the hospital within 24 hours and/or 30 days of discharge.* Evaluates patients/family needs and identifies problems related to compliance with medical care, being alert for signs of abuse and neglect, exploitation, and alcohol and substance misuse concerns.* Coordinates services as appropriate including nursing home placements and returns, medication assistance, referrals to home health / medical equipment / homemaker services, transportation needs, and/or communicating with nursing homes regarding hospitalized residents progress. Per discharge needs assessment.
• Communicates daily with members of the interdisciplinary team to identify priorities and plan interventions accordingly.* Leads the discharge planning process by initiating services needed for efficient discharge planning and reduction in length of stay.* Provides social service consult by referral and follow-up as needed.* Communicates with interdisciplinary team regarding identified needs and/or barriers and discharge plans daily.* Communicates completely and frequently with patients/families when developing a discharge plan.* Assists with multidisciplinary care conferences as necessary.* Demonstrates the ability to mulch-task and implement time-management skills efficiently.* Demonstrates accountability for personal and professional standards and competency in accordance with the hospital as well as their profession's ethical guidelines and standards.* Participates in the orientation program for new staff, volunteers, and students as assigned.
• Serves as a resource of broad knowledge with regards to hospital and community resources related to emotional and financial support for patients and/or families, collaborating with Risk Management personnel to address related issues as needed.* Acts as a resource, consultant, and liaison for the interdisciplinary team and patients, their support system, and the community.* Advocates for patient needs within hospital and community to ensure patients have education and/or access to services needed for successful hospital discharges and reduction in potentially avoidable hospital readmissions.* Acts as an advocate for the patient and their support system with hospital and community social and financial resources to ensure patient needs are met.* Provides emotional support to patients and their support system to assist them in mentally and emotionally adjusting to their change in health status.* Facilitates guardianship proceedings, in collaboration with risk management, when warranted. * Assists with identification of under- and over-utilization of services.* Assists in identification of barriers and problem-resolution for complex patient populations.* Possesses real-time knowledge of updated community and hospital resources.* Assists in counseling on Advanced Directives as appropriate.
• Assists with documentation in the EMR.* Documents all Discharge Planning components accurately in EMR.* Assists with documentation in EMR to support quality initiatives.* Assists with audits for medical necessity documents as request

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