Medical Social Worker - Cherokee Nation

The Medical Social Worker comprehensively plans for services for a targeted population in the hospital and ambulatory health centers. Responsible for psychosocial assessments, crisis intervention, discharge planning, and coordination of referrals and resource information to patients and families in need of assistance. Independently identifies complex patients as well as receives referrals from doctors, nurses, administrative staff, physical therapists and other ancillary staff. Provides an array of social work services to patients and families to promote understanding and resolution of problems related to environmental stress, physical illness, interpersonal conflicts, and other psychosocial issues. Certain issues addressed by Medical Social Workers include terminal illness, catastrophic disability, end of life decisions, homelessness, independent living resources, medication adherence and management, or suicidality. Adheres to the patient experience initiatives and champions customer service. Works collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum at the appropriate level of care.

Conducts face-to-face interviews with patients and family members to develop therapeutic relationships and obtain psychosocial and financial information necessary for the facilitation of appropriate discharge planning.  Performs proactive screenings and assessments for patients’ clinical, psychosocial, and discharge planning needs through personal contacts with patients and family members, review of medical charts, and collection of information from medical staff personnel and interdisciplinary patient care meetings.  Documents assessment, the on-going plan, case progress, intervention(s), and reassesses patients as needed in medical record according to facility requirements, licensure and regulatory guidelines.  Identifies and documents clinical, psychosocial and financial barriers to a smooth transition across the healthcare continuum and assists in identifying and facilitating system improvements.  Coordinates activities to progress the patient through the healthcare continuum. Initiates referrals and recommends consults to enable patient to be prepared for safe and timely discharge or transfer.  Anticipates and proactively works to prevent delays and barriers to care delivery; collaborates with involved persons/departments to resolve barriers that may occur.  Provides support and education to patient/family. Assists patient/family in coping with hospitalization, disability, and chronic/terminal illness.  Assists patients to understand their diagnosis and make the necessary adjustments to their lifestyle, housing, or healthcare.  Serves as a resource to hospital staff and ambulatory physicians regarding emotional, social and psychosocial components of patient illness. Ensures integration of the interdisciplinary team in understanding and integrating these aspects into the plan of care.  Research, refer, and advocate for community resources, such as food, childcare, and healthcare to assist and improve a patient’s well-being.  Provides crisis intervention, mental health emergencies, end of life support, and initiates referrals to appropriate resources to ensure patient/family psychosocial and emotional needs are met.  Delivers Important Message from Medicare to patients and explains content and responds to questions followed by documentation of services performed.  Utilizes communication, negotiation, and advocacy skills with patient, family, healthcare team and community. Develops positive relationships with post-acute care providers and community services.  Maintains current knowledge and awareness of community resources for social, emotional or financial assistance.  Provides information, education to patient/family on community resources and options for post-acute care appropriate to the age of the patient served. Initiates referrals to community agencies as needed. Ensures patient is provided choice of post-acute facilities/ agencies per HIPAA regulations and Center for Medicare/ Medicaid Services.  Carries out discharge planning activities to include providing arrangements for Home Health, Hospice, Home Infusion, DME, Outpatient Hemodialysis, Rehab, LTAC, Assisted Living, Rest Home and Skilled Nursing Facility placements. Serves as patient advocate. Enhances collaborative relationship to maximize the patient’s and family’s ability to make informed decisions.  Understands placement intricacies and can interpret requirements from state, local and federal agencies to optimize placements of patients in the most appropriate setting. Aligns needs of patient with appropriate placement option.  Provides alternate plan of care options at the appropriate level of care based on patient/family needs and in collaboration with physician and/or designated team members.  Coordinates the plan of care with the interdisciplinary team and communicates to the patient/family verbally and in writing to meet the patient and organizational needs.  Serves as a resource for processing issues such as guardianship, abuse, neglect, power of attorney, healthcare surrogate, advance directives or psychiatric involuntary commitment. Initiates/completes forms required for post-acute placement.  Identifies and refers cases to the Leadership Team for Physician Advisor review in a timely manner to address patient needs.  Adheres to mandates, standards, and policies and procedures as determined at the federal, state, health system and department level as well as the National Association of Social Work Code of Ethics.  Promotes positive customer service and service orientation in the performance of position duties and responsibilities and interactions with patients, hospital staff and visitors.  Participates in continuing education and applicable hospital mandatory training.  Serves as a reliable resource for the Acute Care Nurse Navigator for difficult placements, information on Medicaid and disability, and Department of Social Service Referrals.  Consults with the Acute Care Nurse Navigator when clinical explanation of disease processes, clarification of physicians’ orders, and other pertinent information is needed to determine, safe appropriate discharge plan.  Other duties may be assigned.

SUPERVISORY RESPONSIBILITIES

None.

EDUCATIONAL REQUIREMENT

Master’s degree in Social Work; no substitutions.

EXPERIENCE REQUIREMENT

No additional experience required.

COMPUTER SKILLS

An individual should have knowledge of Word Processing Software.

CERTIFICATES, LICENSES, REGISTRATIONS

Preferred a Licensed Clinical Social Worker or Licensed Mastered Social Worker.

OTHER QUALIFICATIONS

The employee must not be and will not be under sanction by the United States Department of Health and Human Services Office of the Inspector General (OIG) or by the General Services Administration (GSA) or listed on the OIG's Cumulative Sanction Report, or the GSA's List of Excluded Providers, or listed on the OIG's List of Excluded Individuals/Entities (LEIE). 

Must meet and maintain periodic background investigation and adjudication for child care.

PHYSICAL DEMANDS

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit. The employee is occasionally required to stand and walk; No special vision requirements.

WORK ENVIRONMENT

The noise level in the work environment is usually quiet.