Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Social worker of the Department of Medicine, Geriatrics oversees management and coordination of Social Work Services provided in the outpatient setting across multiple offices. Plans and implements programs to meet the social and emotional needs of patients and patients' families in the outpatient setting. Coordinates the ACO nurse navigator, medical assistants, Dept. of Medicine Program Director, physicians, and other members of the healthcare team to ensure appropriate utilization of resources, care planning, health education, patient satisfaction and revenue recovery.

• Develops and maintains an effective Outpatient Social Services program consistent with any regulatory and reviewing agency requirements, by planning, organizing and executing day-to-day operations of the Outpatient Social Services Program.
• Serves as a HackensackUMC representative and resource for Community and Regional services at the appropriate outpatient level. This includes, but not limited to, coordination with Home Healthcare Agencies, Long-term Care facilities, Rehabilitation facilities, medical equipment companies and medical transport companies.
• Facilitates communication and coordination between members of the health care team and involves the patient/family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the plan of care.
• Maintains current and up to date information of community resources and refers patients to those community resources which will enhance the patient's life. Consults with other community agencies and committees to identify potential resources to support patients and their families.
• Expands upon current resident education in the outpatient setting and provides educational support to residents in the clinic to further develop their clinical assessment skills (e.g. social history, psychiatric history, substance abuse history).
• Participates in the development of department policies and procedures and process improvements.
• Maintains program reports and statistics for administrative and regulatory purposes.
• Serves as the subject matter expert in social service practice for Hackensack University Medical Group.
• Adheres to the standards identified in the Medical Center's Organizational & Managerial Competencies.
• Will coordinate efforts that will help HUMG achieve its quality goals and help prevent, whenever possible, the readmission of patients who are recently discharged from the inpatient setting.
• Participates in supervisory activities including interdisciplinary case conferences, quality improvement and program development.
• Collects, manages and analyzes relevant data.
• Oversees the ongoing assessment of patients¿ social service and psychosocial needs and monitors the delivery of such services.
• Partners with Hackensack's Preferred Providers to improve patient's ability to navigate outpatient services across the HMH network.
• Creates and maintains relationships with all post-acute facilities, DME companies, and visiting nurse agencies to better coordinate outpatient care and review data to determine where improvement in communication can occur.
• Coordinates all aspects of case management working in close consultation and collaboration with physician, family, patient, health care team and community.
• Knowledge of state and federal programs that provide medical care and financial support to individuals.
• Performs a psychosocial assessment on referred patients and families to help to identify needs regarding illness, hospitalization, finances, psychosocial and support needs.
• Plays a vital role in providing health education to patients in the outpatient setting.
• Work closely with the Charity Care office to ensure the completion of Charity Care applications.
• Counsels patients and families in coping with immediate and long-term problems. Provide financial counseling to families/patients pertaining to Charity Care, Medicaid, Medicare, etc.
• Coordinates and provides Social Work Services for patient populations including adult and geriatric patients and their family members or significant others who have multiple problems; dysfunctional family structure, irregular work history, limited social support, poor finances or other high-risk criteria.
• Acts as liaison with Medicaid and housing resources, when applicable.

• Master's degree in Social Work (MSW).
• Minimum of 1 years of prior experience as a Masters level Social Worker in a healthcare setting.
• Minimum of 1 year of experience working with an EMR, specifically EPIC.
• Ability to work with diverse patient and team member/staff populations.
• Strong computer communication,analytical and presentation skills.
• Ability to collect, manage and analyze data.
• Experience with Microsoft Word, Excel, Outlook, PowerPoint, Google.

• Spanish speaking.
• Certification in data analysis or business intelligence (BI).

• NJ Licensed Social Worker.