Position will work with Care Coordination team to ensure patients/families are referred to appropriate programs and community resources and provide psychosocial and financial assistance and facilitate referrals for complex continuing care facilities/services.
Clinical Skills- Obtains relevant essential data to complete a Psychosocial Assessment and Multidisciplinary Plan of Care. Identifies relevant information regarding the patient/family medical condition, emotional status, functional abilities, barriers to learning, primary language, English language proficiency, cultural and religious factors, functional ability, financial situation/resources, and support systems to determine and carry out social work interventions. Effectively uses a variety of therapeutic techniques and modalities in patient/family interventions to achieve optimal outcomes.
Referrals and Service Identification:
Responds to all referrals in accordance with ACO time frames. Participates in patient case rounds, confers with physicians, care team, identifies and prioritizes psychosocial problem areas and pt/family needing social work intervention. Maintains and utilizes a current knowledge base of community agencies and facilities. Refers patients/families to appropriate programs and community resources in a proactive and timely manner. Provides appropriate follow-up with patient/family on their efforts to follow through with referrals. Facilitates referrals for complex continuing care facilities/services.
Ongoing collaboration and communication with ACO Care Coordination team members/interdisciplinary team to update and reassess changing psychosocial needs, medical needs, and plan of care. Proactively communicates with the ACO Clinical Leadership team regarding situations that interfere with the implementation of the patient s care plan. Liaison and patient advocate with community agencies, health care delivery system services and third party payers, when indicated.
Through the model of Shared Governance, collaborate with all members of the health care team with a focus on promoting evidenced based care within a healing culture for the patient population served and their families.
Candidate will demonstrate and embrace the PRIDE core values (Professionalism, Respect, Involvement, Dignity and Excellence) in every aspect of their job.
BSW from an accredited school with a MSW and LCSW required
3-5 years experience in a hospital/ case management setting
Atlantic Health System aims to deliver the highest quality and care combined the best experience for our patients and their families. We are confident that you will find success within Atlantic Health System, which has been named for the 9th year in a row to Fortune’s “Top 100 Best U.S. Companies to Work For” list. We believe you’ll find that our culture of collaboration and care exemplifies the value we place on our patients, their families and our employees.
All qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran
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