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Job Summary:

The Social Worker (BSW) or (MSW) will organize and expedite a treatment plan of care for medically complex and difficult social issues related to hospital progression of care. The incumbent will identify discharge needs and develop a discharge plan, promote communication and collaborative coordination amongst care providers, and provide information and education on community resources. Additionally, the position will coordinate care of patients with clinical partners, provide intervention in cases of child/elder abuse/neglect and guardianship issues, and serve as a resource for treatment decisions surrounding end of life and Medical Power of Attorney.

Essential Functions and Responsibilities:

• Coordinates care of patients with clinical partners; helps patients advance towards realistic and desirable outcomes.
• Assesses long term and/or future patient care needs by identifying probable changes in level of independence or functional quality.
• Communicates activity status updates regarding treatment plan with clinical partners.
• Provides information and education on community resources to patient and their families.
• Develops, coordinates, and communicates discharge plans with the patient, family members and care team for medically complex and difficult social issues related to hospital progression. Documents assessment and overall discharge plan in medical record.
• Collaborates with leadership to appropriately address concerns related to delays in discharge, barriers to discharge and trends noted.
• Provides intervention in cases of child/elder abuse/neglect and guardianship cases.
• Serves as a resource person related to treatment decisions surrounding end of life and Medical Power of Attorney.
• Facilitates meetings and comprehensive care planning with interdisciplinary team. Delegates work to support team members.
• Utilizes post-acute care facilities for safe and effective discharge planning.
• Collaborates with contracted partners associated with financial needs to facilitate post-acute facility placement.
• Conducts psychosocial assessment as needed for development of appropriate discharge plan for medically complex and difficult social issues.
• Performs other duties as assigned.

• Qualifications:

• Master's degree in Social Work required.
• A minimum of one year experience in social work required or two-semester internship completed within MWHC Care Coordination department
• Experience with computer technology, specifically experience with Windows based programs, e-mail, and Microsoft Word required.
• Experience in a healthcare field preferred.
• Case Management Certification strongly desired

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.