Job Description

Create optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Through advanced practice skills, mobilizes resources to reduce risk, and serves as ambassador between hospital and community. Works with the Case Manager and the treatment team to develop a safe and timely Discharge Plan A and B that complies with regulations and laws regarding patient and family wishes. Identifies the need for and conducts family meetings that result in comfort, decisions, and other important outcomes. Serves as the lead in obtaining charity and financial resources, legal guardianship, adoptions, psychiatric referrals, and competency determinations. Leads or co-leads Care Coordination Rounds. Help create function and productivity on the many teams to which the SW belongs, facilitating the resolution of conflict to present a united message to patients and families. Acknowledge issues of diversity and adjust practice accordingly. Works with people and agencies in the community to improve responsiveness, capabilities, alignment, and evaluation of services to patients and families. Collaborate with Risk Management, Patient Relations, Utilization Management, and Quality Management about potential problems and preclude outcomes detrimental to AMC. Base individual practice patterns on a sound knowledge base of social work principles and methodologies, social work policies, and the NASW Code of Ethics. Demonstrate flexibility in providing department coverage as needed, including possible modification of role, responsibilities, and assigned caseload. Completes initial screen of patients and families and a comprehensive psychosocial assessment of patients. Assists patients and families in understanding their illness and treatments options, as well as consequences to various treatments or refusal of treatment. Assists patients and families in communicating with treatment team. Provides crisis intervention. Advocates for patient care and timely discharge plan. Coordinates patient discharge and continuity of care planning. Educates hospital staff on patient psychosocial needs. Educates patients and families on levels of care; acute, sub-acute, community services and resources. Minimum Qualifications: New York State Licensure (LMSW) required as of 7/01/16. Master of Social Work degree from an accredited school of Social Work Program. One year as graduate student or as a social worker with experience in the field of Clinical Social Work with experience in care transitions. Ability to create collegial and collaborative relationships internally and externally. Knowledge of accreditation standards, health care regulations, performance improvement and patient safety. Effective organization, oral and written communication skills, problem solving, program development and computer skills. Knowledge of health care law and regulations related to acute care and the immediate post-acute continuum. Ability to complete a psychosocial assessment, risk factor analysis, treatment planning, and models of intervention.

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