Care Coordination Master Social Worker

Baylor St. Luke’s Medical Center is an internationally recognized leader in research and clinical excellence that has given rise to breakthroughs in cardiovascular care, neuroscience, oncology, transplantation, and more. Our team’s efforts have led to the creation of many research programs and initiatives to develop advanced treatments found nowhere else in the world. In our commitment to advancing standards in an ever-evolving healthcare environment, our new McNair Campus is designed around the human experience—modeled on evidence-based practices for the safety of patients, visitors, staff, and physicians. The 27.5-acre campus represents the future of healthcare through a transformative alliance focused on leading-edge patient care, research, and education. Our strong alliance with Texas Heart® Institute and Baylor College of Medicine allows us to bring our patients a powerful network of care unlike any other. Our collaboration is focused on increasing access to care through a growing network of leading specialists and revolutionizing healthcare to save lives and improve the health of the communities we serve. As our Social Worker, you will be a compassionate advocate, providing vital support and guidance to individuals and families facing complex challenges. Every day, you will conduct psychosocial assessments, develop care plans, provide counseling and crisis intervention, and connect clients to resources. You'll advocate for clients and collaborate with multidisciplinary teams to ensure holistic support and promote well-being. To be successful in this role, you will possess exceptional interpersonal skills, empathy, strong knowledge of community resources, and proven crisis management abilities, fostering positive change and client empowerment. Providing developmentally appropriate care for all populations served: plan for the safe discharge and continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients. Advocacy and education: patient/family self-care management; patient/family health management education; bioethics referrals and management; physician, staff, and community education; case/care management/coordination education and training; risk management identification and referral. Psychosocial management: crisis intervention; psychosocial assessment/functioning; counseling support and referral; abuse/neglect/trafficking identification, assessment, and referral (partner, child, elder, etc.); family issues affecting care; coping/emotional adjustment; grief/bereavement support (individual and group); adoption, surrogacy, and safe surrender support, management, and resources; health/wellness promotion; substance abuse screening, management, and resources; psychiatric screening, management, and resources; staff support; assessing, addressing, managing, and resources related to social determinants of health (e.g. housing and food insecurity, transportation). Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning and management. Continuity/Transition Management: As part of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to clinical social work scope of service and functions and social worker discretion; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; grave disability, palliative care/end-of-life, and hospice patient/family support, referrals, and management; interventions, management, and coordination of transition planning for psychosocially complex cases. Community Resource Coordination: life-care planning; expert consultation on health care resource management; team and patient education regarding various health-related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social determinants of health needs. Required Masters Other Social Work and 1-Year Post-MSW experience or Social Work internship in a clinical or medical setting., upon hire and Master Social Worker: TX, upon hire or Preferred Minimum 3-Year Post-MSW healthcare experience