The Social Worker BSW coordinates and facilitates patient care activities to improve continuity of care across the health care continuum, to promote appropriate utilization of resources, and to contribute to improved patient satisfaction and outcomes. The BSW provides services and support to patients and families who are referred to Social Services or by case finding. The BS provides discharge planning as needed. The BSW is a strong patient advocate. Working in collaboration with the Patient Navigator and the Multidisciplinary team, the BSW assesses and intervenes with high risk patients that require a high level of continuing care services while ensuring compliance with regulatory standards of care at the organizational, state and federal level. As needed, the Social Worker conducts clinical review for utilization management; corresponding with payers and utilizing established criteria sets.
Responsibilities
Essential Duties and Responsibilities
- Provides psychosocial assessment, intervention and facilitates referrals to community resources to hospital patients in a variety of care settings.
- Formulates, develops and implements psychosocial treatment plan utilizing appropriate social work interventions which may include crisis intervention and grief and bereavement services.
- Assesses referred patients, within prescribed time frames, for transitional planning needs, including any barriers to discharge, family and social supports, capacity for self-care, adaptive abilities and financial resources.
- Develops individualized, patient-focused plan for meeting continuing care needs.
- Provides education and resource options available to patients and families. Facilitates and assists with legal issues within scope of practice (POAHC, Guardianship, Patient Rights, and Adoption).
- Reviews advance directives and helps patients to complete new documents.
- Communicates effectively with physicians, patients, families and multidisciplinary team to ensure that the patient's right to self-determination is met.
- Provides education and support to patients/families in regards to issues related to adaptation to the patient's diagnosis/illness/treatment and/or life situation.
- Maintains detailed knowledge of community resources to effectively address patient needs and help to strengthen patient's network of support.
- Documents plan of care, interventions, and progress toward goals in the medical record in a timely and concise manner.
- Facilitates crisis intervention services in the hospital setting as determined by scope of practice.
- Identifies and reports child and/or elder abuse to local authorities according to law.
- Acts as a liaison with county officials for patients involved with protective services, aging, developmental disabilities, domestic violence, mental health services and economic support.
- Maintains current knowledge and awareness of payer/reimbursement practice and regulations impacting the patient's plan of care.
- Negotiates care issues as appropriate (indigent issues and availability of resources).
- Promotes customer satisfaction and intervenes at critical moments of service.
- Monitors inpatient readmissions for potential failed discharge plans or need for specialized intervention.
- Provides follow-up with patients as needed.
- Assists with identifying avoidable day information for organizational tracking and trending.
Culture of Excellence Behavior Expectations
To perform the job successfully, an individual should demonstrate the following behavior expectations:
Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.
Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.
Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.
Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.
Education and Experience
Bachelor's degree from accredited college or university (BSW or equivalent) required. One to two years related experience and/or training in acute care setting is desirable.
Certification and Licensure
Current Wisconsin Social Worker License required.
Case Management Certification (ACMA) preferred
Skills and Abilities
Phone Skills
Must be skilled with use of voice mail and phone features. Must be able to use available technology for language interpretation.
Computer Skills
Must have expert knowledge of Allscripts Care Management program and Epic EMR. Must be able to use Microsoft Outlook; and have basic knowledge of Excel and Word. Must be able to toggle between computer applications.
Must be available to work and or be on-call during weekends and holidays, as assigned. On-call requires accessibility by pager or cell phone during assigned hours and ability to respond promptly to pages by phone.
Special Physical Demands
While performing the duties of this Job, the employee is frequently required to sit, talk and hear. The employee is occasionally required to stand, walk, handle, finger, feel, and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include frequent close vision and occasional distance vision and ability to adjust focus. Specific fine motor abilities required include writing, keyboard entry and mouse use.
Level of Supervision
Assignments are based on abilities and are normally received in the form of results expected and due dates. Only general procedures are available to guide work. Must be able to work independently with minimal guidance
Supervises
N/A