Position: Social Worker
Location: Silver Spring, MD, 20910
Contract: 13 week
Shift: 08 am – 16:30 pm
Pay Scale : $ 1800 – $ 2000 Weekly gross
Roles & Responsibilities:
- Collaborates with Care Transition team and Health Advocates for high-risk patients for timely follow-up appointments and confirms prior to discharge that complex patients are appropriately linked to community services.
- Coordinates patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners and makes referrals as appropriate.
- Effectively intervenes in suspected abuse/neglect cases and in complex or high-risk situations as requested; is competent to identify and intervene with high-risk behaviors, responding to traumas.
- Identifies and mobilizes patients and family strengths to optimize use of healthcare and community resources; in coordination with patient and family wishes, guide/assist in securing needed post discharge services which may require negotiating for services covered but not readily available; provides consultation and education to team members regarding patient/family (psychosocial and discharge planning) issues and community resources.
- Identifies potential problems prevents and or resolves variances to the care management plan; assesses and coordinates family and community resources to meet identified needs to support the discharge plan.
- Intervene with patients and patient's representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability.
- Leads patient cantered conferences to meet needs and desires of the patients.
- Maintains patient records including patient assessments, plans interventions, patient/family involvement, outside agency communications and interdisciplinary contacts.
- Participates in discharge planning activities; effectively identifies and intervenes with high-risk discharge planning issues with psychosocial complexity; whether referred by other healthcare providers or identified through assessment. Assists Care Management Nurse with discharge planning efforts as requested; obtains or coordinates referrals for post-discharge service needs, if required; mobilize resources to affect rapid and timely movement of the patient through system to achieve targeted discharge times established by AHS.
- Performs psychosocial assessment interview with patients and/or families and records this assessment in the patient's medical record. Assesses patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope; reassesses the patient's condition when changes occur and revises the care plan when appropriate. Performs rapid assessments and developing crisis management plans for referral, evaluation and admission.
- Provides patient advocacy including primary responsibility for initiating processes regarding capacity determinations, grief counseling, and conservatorship/guardianship; takes advocacy leadership role regarding adoption/surrogacy cases.
- Refers and assists patients/families in applying for appropriate financial programs (CCS, SDI, SSI, SSD, private pensions) and legal instruments as needed.
- Screen for any barriers to care such as substance abuse, neglect, financial limitations or housing.
- Serves a resource and provides counseling and treatment related to palliative care or end of life planning.
- Provides crisis intervention, bedside counseling and resources/referrals for mental health care.
- Required Education: Master's degree in social work/welfare issued by a school accredited by the Counsel of Social Work Education.
- Required Experience: Two years of post-graduate social work or Case Management experience in a medical setting or community agency. One year of social work internship in an acute care hospital may be considered.
- Preferred Experience: 1 year’s acute care hospital setting
- Preferred Licenses/Certifications: Active License for the state. Current and valid license as a Clinical Social Worker issued by the State Board of Behavioral Science Examiners.
- LCSW or PPSC must.
Recruiter Email: [email protected]
Phone : 408-580-9335