MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1.Masters Social Work Degree required

2. LGSW/LCSW/LICSW certification in the state of West Virginia required

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. One to three years of experience preferred

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Manages all aspects of transition/discharge planning for assigned patients in a timely manner using escalation processes as needed when barriers encountered.

2. Collaborates with all members of the multidisciplinary team to facilitate the transition/discharge process for designated caseload

3. Monitors the patient's progress; intervening as necessary and appropriate, to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective

4. Maintains extensive knowledge of federal, state, and local assistance programs and community resources that affect patient needs.

5. Demonstrate appropriate professional practice, maintaining respect for confidentiality and freedom of choice as outlined by the Code of Ethics by the National Association of Social Workers as well as the State Board of Social Workers.

6. Provides education as needed to staff, physicians, and patients and their families to ensure effective transition planning

7. Meets directly with the patient and/or family to assess needs and develop an individualized transition/discharge plan in collaboration with the physician team

8. Provides social work assessment and interventions for complex crisis including but not limited to mental health, substance abuse, adjustment to health status and grief/loss situations.

9. Communicates with the multidisciplinary team and post-acute providers when applicable, any complex family dynamics that may directly impact patient care and transition/discharge planning

10. Initiates and facilitates referrals to post-acute services- including but not limited to- Homecare, Durable Medical Equipment, Hospice Care, Long Term Acute Care Facilities, Acute Rehab Facilities, and Skilled Nursing Facilities

11. Communicates all necessary information regarding transition/discharge plan to the multidisciplinary team, patient and family. Assists other team members to understand and appreciate a patient and/or family's reaction to a serious illness and/or chronic illness/disease as well as to understand other environmental factors affecting care, treatment and compliance.

12. Provides timely and comprehensive documentation of interactions with patient and/or families and all transition/discharge planning activities and progress according to regulatory policies and procedures.

13. Working knowledge of patient's current medical insurance coverage and limitations and the precertification requirements for Durable Medical Equipment (DME), post-acute placements, infusions, transfers etc.

14. Assists patient/families with completion of medical power of attorney, health care surrogate, and advanced directives

15. Utilizes clinical skill and expertise to provide assessment, intervention, and where appropriate, reporting for complex abuse, neglect, Foster Care, adoption, Mental health placement, homelessness, domestic violence, and sexual assault situations.

16. Collaborate for appropriate resource and financial management which may include but is not limited to-financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination

17. Communicates with the Care Management Resource Center and/or third party payors to facilitate covered day reimbursement certification for assigned patients and discusses payor criteria and issues on a case by case basis with clinical staff (Ie: peer to Peer) and follows up to resolve problems with payors as needed

18. May require occasional coverage to outpatient services including but not limited to LVAD assessment/services, Transplant psychosocial assessments and services and for coordination of discharge services with the outpatient organ transplant/LVAD clinic staff.

19. Uses quality screens in the electronic record to identify potential issues including but not limited to- avoidable delays and readmissions

20. Educates hospital staff and physicians to payer regulations and managed care principals to prevent denials

21. Fosters the integration of staff and/or students into the healthcare team

22. Exhibits professional behavior on a consistent basis

23. Required on call and weekend/holiday rotations as needed

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS AND ABILITIES:

1. Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues.

2. Ability to work with people of all social, economic, and cultural backgrounds and be flexible, open minded, and adaptable to change

3. Capable of independent judgment and action regarding psychosocial needs of patients.

Additional Job Description:

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