In collaboration with patients, families, caregivers, and interdisciplinary staff across all disciplines, departments, and care settings, the Medical Social Worker is responsible for providing psychosocial and clinical trauma informed social work services to members experiencing with illnesses ranging from terminal to complex. This role supports safe, timely and patient centered transitions across the care continuum by conducting biopsychosocial assessments and ongoing support. The Medical Social Worker will provide support and guidance to interdisciplinary care teams while maintaining strong relationships with other involved teams such as facilities and community partners involved in patient care.

This position is considered Hybrid, which means that individuals in this position may work both at an approved Offsite location and Onsite at a primary location or multiple locations based on Business Needs.

Essential Duties:

• Supports the assigned department with medical and clinical social work and care transition functions with a strong emphasis on psychosocial, behavioral health and substance use disorder and service coordination for complex
  discharges and aftercare.
• Develops professional relationships with advanced knowledge of aftercare resources, including eligibility, scope and referral process requirements to improve member safety in the community.
• Supports timely transitions and strengthen access to behavioral health, substance use treatment, post-acute care, home based services, housing, public benefits and entitlements.
• Conducts comprehensive psychosocial and biopsychosocial assessments to evaluate member, family, caregiver and environmental factors that may impact health outcomes, care transitions, and overall well-being. Assessments
  include, but are not limited to, family dynamics, coping abilities, behavioral health needs, trauma history, substance use, caregiver capacity, adjustment to hospitalization, and social drivers of health in order to: Share information with other multidisciplinary team members that will enhance the effectiveness and outcome of the plan-of-care, identify barriers to successful health maintenance, treatment adherence, and successful transition for member, identify risk of onset or prior existence of psychiatric diagnosis, behavioral health conditions, substance use disorder, trauma, caregiver breakdown or unsafe discharge conditions, make appropriate recommendations/referrals to community resources, behavioral health services, and home-based services
• Prevent communication breakdown between member, families, providers, and staff by balancing advocacy and facilitating complex family meetings, conflict resolution, and supporting discharge planning in high- risk cases.
• Identifies suspected or actual abuse, neglect, exploitation, human trafficking, domestic violence, self-neglect, and other safety concerns; completes mandatory reporting to appropriate agencies as required by law and policy; and develops safety plans and crisis interventions as clinically indicated.
• Provides support and serve as a resource to members/families experiencing illness and/or psychosocial issues, including but not limited to grief/loss, serious illness adjustment, caregiver stress, family conflict, behavioral health
  needs, substance use concerns, and end-of-life transitions utilizing social work interventions.
• Identities root cause of frequent medical and/or behavioral health readmissions and address them within the scope of social work including culturally based perceptions of illness and health, poor understanding of life-changes
  secondary to disease, caregiver limitations, lack of community resources and other social drivers of health impacting the member.
• Partners with interdisciplinary team on strategies to reduce avoidable readmissions and outcome disparities.
• Incorporates independent thinking, professional judgment, discretion, and initiative when interfacing with physicians, providers, nurses, case managers, community health workers, and other health care professionals as well as Members, families, and/or caregivers.
• Handles confidential and time sensitive materials including clinical information subject HIPAA requirements in accordance with licensure, regulatory and organizational standards.
• Utilizes technology systems to document assessments, interventions, referrals, care coordination activities, and to facilitate communication to support care transitions.
• Participate in staff consultations, interdisciplinary case review for ongoing care coordination.
• Performs all roles and responsibilities in a timely manner.
• Serve as a mentor or preceptor.
• Performs other duties as assigned
  
  

Knowledge/Skills/Abilities:

• Strong knowledge of medical social work practice including psychosocial and biopsychosocial assessment, discharge planning, care transitions, crisis intervention, family systems, behavioral health, substance use and social determinants of health.
• Working knowledge of community agencies/resources, financial programs, i.e., TANF/SSI and familiarity with principles of growth and development Ability to work with multidisciplinary staff across medical, behavioral health, post-acute, and community settings.
• Previous experience in transitions of care setting Ability to demonstrate independent judgement, discretion, and sound clinical decision making when handling sensitive and confidential information.
• Fosters a positive, collaborative work environment that promotes exceptional customer service and
  member satisfaction.
• Ability to prioritize and manage a high-volume workload with competing and changing demands
  while maintaining accuracy, attention to detail and timely completion of tasks.
• Strong interpersonal skills with the ability to interface effective both externally and internally with a wide range of people
• Strong problem solving skills with effective follow through
• Strong listening, verbal, presentation and written communication skills
• Ability to perform moderately complex operations using organization technology such as Microsoft
• Office Suite and electronic health record.

MINIMUM EDUCATION: Bachelor's Degree (higher degree accepted) of Social Work from an accredited school of Social Work

MINIMUM EXPERIENCE: A minimum of three years of experience in medical social work with vulnerable populations is required

REQUIRED CERTIFICATIONS/LICENSURE: 
Driver's License Valid Driver's License Upon Hire Required