Summary

In collaboration with patient/family, physicians and the interdisciplinary team, the Social Worker II is responsible for coordination of patient-centered care and service delivery to facilitate optimal transitions and progression in care. The social worker is responsible for coordination and collaboration of care with patient, caregiver, physician and other members of the health care management team. The social worker collaborates and communicates with the healthcare team and involves the patient/family in the plan of care and responsible for coordinating and monitoring social work activities for the department and works closely with management to identify and resolve care issues. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Education/Experience/Licensure

Knowledge/Skills/Abilities

• Excellent interpersonal skills, including ability to work collaboratively and cooperatively within an integrated interdisciplinary team.
• Comprehensive knowledge of community resources.
• Knowledge of and ability to gather relevant data to synthesize and summarize information in making judgments regarding patient care.
• Excellent oral and written communication skills necessary to communicate/exchange and interact effectively and professionally with hospital staff, agency health care professionals, patients and families.
• Ability to use a variety of social work interventions.
• Demonstrates knowledge of family systems and human development across the life span.
• Ability to use initiative in decision-making; independent judgment and critical thinking skills.
• Demonstrated ability to develop and maintain working relationships with physicians and work collaboratively with health professionals at all levels to achieve established goals.
• Demonstrates cultural competency and knowledge of interventions with special populations.
• Adaptability to a fast-paced environment of constant change and continuous performance improvement.
• Proficient in basic word processing skills (Word), internet navigation, and electronic medical record

Key Job Responsibilities

• Demonstrates values and standards of the social work profession and performs and participates as part of the Case Management team to support in a collaborative effort to facilitate quality patient care. This role integrates and coordinates various aspects of service delivery, care facilitation, service access, and discharge and post-discharge activities
• Completes an initial screen of all assigned patients to identify readmission risks, patient strengths and needs related to clinical resource utilization and transition planning; initiates, completes and documents transition planning for patients in assigned caseload.
• Communicates necessary information to stakeholders and educates patients and families.
• Plans effectively to meet patient needs, manages length of stay, and promotes efficient utilization of resources (fiscal, human, environmental, equipment and services).
• Advocates for the safe discharge of patient to home or community resource, and supports preventive and follow-up care post-discharge
• Maintains reliable systems to document, track, and monitor assigned cases.
• Performs other job functions as assigned or requested

Physical Requirements

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: medium work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
• The Associate is required to have close visual acuity including color, depth perception, and field of vision to perform an activity, such as assessing patients, preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
• Exposure to patient body fluids as well as exposure to hazardous or poisonous materials.
• Ability to react quickly to emergency situations; may be required to take call for nights/weekends on a rotating schedule.