Behavioral Health Social Worker

The Social Worker is responsible for performing social work screenings and interventions for hospitalized and emergency department patients in consultation as needed and collaboratively with the Care Coordination and multidisciplinary healthcare teams. The functions of the Social Worker include: patient/family support and referrals, social needs screening, referrals for financial or other identified resource needs, arranging family/patient representative meetings with the healthcare team as needed, assist in post-acute placement of complex discharges and engagement of appropriate agencies or community resources when patient’s social needs are identified. Employees are accountable for demonstrating a strong commitment to our organizational values of: Compassion, Inclusion, Integrity, Excellence, and Collaboration.

What You'll Do:

• Providing developmentally appropriate care for all populations served: plan for the safe discharge and continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients.
• Advocacy and education: patient/family support; patient/family health management education; healthcare team and community education; case/care management/coordination education and training; social needs identification and referral.
• Complex social needs management: social needs screenings; determination of patient functioning and availability of support systems; support in addressing social needs and making related referrals; escalation of identified cases involving abuse, neglect, trafficking, complex family issues affecting care, grief/bereavement support (individual and group), adoptions, surrogacy, safe surrender, substance use and abuse, and significant mental health or psychiatric concerns; addressing, managing, and referring resources related to social determinants of health (e.g. housing and food insecurity, transportation).

• Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning and management; share in responsibility for identifying appropriate decision makers if the patient is unable or without capacity.
• Discharge/Transition Management: as member of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to social work scope of practice; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; assistance in referral and management of grave disability, palliative care/end-of-life, and hospice patient/family needs; interventions, management, and coordination of discharge/transition planning for socially complex cases.
• Community Resource Coordination: life-care planning; consultation on healthcare resources; team and patient education regarding various healthcare-related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social needs.
• Documentation: thorough, accurate, and timely documentation of, but not limited to, screenings, care recommendations, patient, family, and collateral contacts, discharge/transition planning, and referrals.
• Performance & Outcomes Management: understanding and application of federal/state/local regulatory agency guidelines, The Joint Commission standards, and other regulatory and accreditation requirements; implement evidence-based practices; support organizational financial performance, length of stay, cost per case, readmission prevention efforts and revenue cycle goals.
• Provide support and social work services to outpatients if directed by Care Coordination leaders.

• Bachelor’s degree from a school of social work accredited by the Council of Social Work Education
• North Dakota: Licensed Baccalaureate Social Worker (SWORKER:ND)