Social Worker

• Provide patients and families with psychosocial support for chronic, acute or terminal illnesses
• Advise family caregivers and provide patient education and counseling
• Make referrals for other services and address barriers to healthcare access
• Deliver social work services, including psychosocial assessments and intervention planning
• Identify patients requiring social work intervention through screening, team meetings and referrals
• Develop individualized plans of care addressing bio-psycho-social needs
• Provide information and assistance for financial or social needs
• Coordinate complex transition plans with patients, families, healthcare teams and community providers
• Use the electronic medical record to monitor, document and communicate patient progress
• Collaborate with interdisciplinary teams and community resources to coordinate care
• Advocate for patient rights and access to protective services
• Report vulnerability or suspected abuse as mandated by law
• Participate in readmission-prevention processes and transition conferences
• Identify and intervene with patients at risk for readmission
• Ensure complete clinical handoffs and facilitate referrals and information transfers
• Support appropriate length-of-stay management
• Perform other duties as assigned