Master Social Work

What You’ll Do What You’ll Do - Job Responsibilities The Senior Guia systematically intervenes to provide clinical social work and complex case management to patients and their families who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies. This position assesses the patient’s plan of care and develops, implements, monitors, and documents the utilization of resources internally and externally and progress of the patient through the continuum of care. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This role participates in an interdisciplinary team (including Physicians, Case Managers, Staff Nurses and other members of the care team) to provide services for high-risk patients and ensure that psychosocial needs are attended to and treated as required across the continuum of care. Essential responsibilities consist of but not all inclusive: Provides comprehensive care coordination to an assigned patient caseload Works collaboratively with patients, family, caregivers, healthcare providers, and external partners to meet complex medical patient needs As part of a multidisciplinary team, develops and carries out a treatment plan by the use of a clinical social work diagnosis, assessment and treatment interventions Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability Assesses, mobilizes and provides follow up on family/community resources to meet social care needs Provides intervention in cases involving elder abuse/neglect, domestic violence, guardianship (temporary/permanent), mental health placement, and sexual assault Initiates and assists patients with advance directives Collaborates with patients/caregivers to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs Formulates care plan of intervention acceptable to the patient, family, and health care team Receives referrals for complex patient problem resolution from case managers or clinical care team members Works in collaboration with the clinical and case management team on transitions of care planning and referrals to post-acute providers Promotes a collaborative process and communication between all health care team members, internal multidisciplinary teams, inclusive patients/clients, families, and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial Advocates utilizing knowledge of applicable laws, regulations, government, and insurance benefits as well as practice guidelines and standards of practice Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system Provides follow up and assistance to patients in a variety of settings: in-home, in-clinic, and in the ancillary setting- hospitals, group homes, skilled nursing fac