• patient flow and throughput;
• quality initiatives;
• facilitating discharge planning;
• coordination of care;
• care transitions; and
• psychosocial support.

• Conducts psychosocial assessments to document history and identify preliminary issues for treatment focus by interviewing the patient and their family members. 
• Complete psychosocial assessments within 72 hours of admission.
• Responsible for interpreting, supporting, and executing hospital and department policies, and procedures with regard to the provision of care in the social services setting. 
• Communicates with physicians to report patient progress, needs, concerns, and potential and actual problems.
• Works closely with all members of the health care team in development of the Master Treatment Plan, based on the psychosocial assessment and accepted social work interventions. 
• Complete the Master Treatment Plan within 72 hours of admission.
• Complete an update to the Master Treatment Plan within 7 days of the completion of the Master Treatment Plan. The purpose of the update is to outline progress towards goals listed in the Master Treatment Plan.
• Provides group and family process-oriented therapies as well as conducts educational and other didactic groups for patients and family members using various professional treatment modalities. Provision of these services includes the prompt completion of ongoing progress notes.
• Provides social work services including short-term individual counseling, community resource planning, and crisis intervention.
• Develops and coordinates an individualized discharge plan for the patient by consolidating treatment team interactions and chart information to determine the patient's aftercare needs.
• Attends regular treatment team meetings to provide social work perspective to total case management of the patient by reading and discussing written progress notes from charts and communicating any state or local agency legal requirement for case management with the interdisciplinary team.
• Develops and maintains thorough knowledge of referral resources throughout the service area.
• Acts as resource person for other members of the health care team, providing in-service education and consultation in understanding the social and emotional factors related to health problems.
• Maintains up-to-date knowledge of Medicare, Medicaid, and other third-party reimbursement sources. 
• Maintains accurate and timely records, including clinical and progress notes, according to department policy. Completes all necessary filing by the close of business each day.
• Maintains up-to-date knowledge of field by participating in continuing education activities.
• Provides positive customer relations in dealing with patients, families, physicians, fellow department employees, other hospital departments, referral resources, service agencies, and others.
• Must provide updated patient information, in person or by telephone, a minimum of two times per week to Guardian/POA/or other identified family contact to each patient.
• Must provide updated patient information a minimum of two times per week to each patient’s referring facility.
• Provide backup services for incoming assessment and referral calls.
• Floats to other departments/facilities as directed and assigned. 
• Maintains a professional approach with confidentiality. Assures protection and privacy of health information as attained through written, electronic or oral disclosures.
• Is prompt and efficient with minimal absences. 
• Cooperates and maintains good rapport with nursing staff, medical staff, other departments, and visitors.
• Seeks guidance and remains knowledgeable of, and complies with, all applicable federal and state laws, as well as hospital polices that apply to assigned duties.
• Complies with hospital expectations regarding ethical behavior and standards of conduct.
• Identifies research, best practice, and/or data driven opportunities for improvement in new and existing work processes, products, and services to improve patient care outcomes in collaboration with the clinical team. Outcome and process measures are based on evidenced based medicine and best practices.
• Partners with and supports physicians in all aspects of patient care and care coordination; engages the patient and family in the plan of care.
• Must diligently communicate and collaborate with all members of the health care team to facilitate the episode of care so the patient receives services in a safe and timely manner, and the patient and family are provided all necessary resources and education.
• Works collaboratively with the healthcare team to mitigate risk to patients, families, visitors, employees, physicians and the system.
• Other duties as assigned.

Job Summary