Social Service Care Coordinator/Medical Social Worker, Social Service, Per Diem

Hours:  Per Diem 

Job Summary:

Responsible for conducting High Risk Screening/Heath Related Social Needs Assessment on all patients assigned; for those who screen in complete an assessment of those needs and provides information and referral services, assist with discharge planning efforts assuring the continuity of care is provided as they transition from hospitalization to next level of care. Is knowledgeable of community services and resources available to provide services to our patients and families. Is available to assist the patient, the patient’s family and other persons significant to the patient with the issues which may develop as a result of illness and hospitalization and services patients of all ages guided by the Culturally and Linguistically Appropriate Standards {CLAS}. Is aware of how Race, Ethnic, Languages, Disability, Sexual Orientation, Gender Identity and Health Related Social Needs may affect care and address those areas of opportunity within the care planning and post discharge process with the multidisciplinary team. May also complete high risk discharge post discharge follow up; Flexibility and adaptability to change is essential.

Essential Functions:

• Provides Case Management Services upon admission through discharge including but not limited to dc planning –engaging client in process ; services may include but are not limited to: housing, primary care; transportation resources, legal services, outpatient therapy med management follow up other social service supports/resources; addresses barriers to treatment or discharge and applications for program assistance.
• Completes documentation using the documentation standards noted by department policies and procedures, as well as, state and federal regulations.
• Works collaboratively with staff on cases and other members of the multidisciplinary team as needed.
• Keeps updated community resources to share with clients; provides update to Director for Community Resource Directory Access and for distribution to clients as needed.
• Completes a statistical record of each case closed, noting recorded hours, contacts made and services provided so that department documentation and statistics can be completed.
• Keeps abreast of department policies and procedures, as well as, state and federal regulation guidelines, (i.e. JCAHO,  DPH, etc.) to ensure compliance with department policies and procedures, as well as, state and federal regulations.
• Completes Utilization Review activities and other duties as assigned by Director.
• Provides information and education to patients and their families regarding the discharge planning  as part of their specific care needs and works closely with members of the multidisciplinary team including, physicians, patients, families, staff,  community agencies including but not limited to LTC Mass Health Applications for SNF placement timely and efficiently with patient, family and/or significant others.
• Covers department as needed in various capacities within their own scope of service.

• Informs patients of their patient rights when indicated (i.e. discharge planning, guardianship, court commitments,

  admission/hospitalization, Power of Attorney, etc.).

Job Requirements

Minimum Education

• Associates Degree required, Bachelor's Degree preferred, in Social Work or related field. 

Minimum Work Experience

• Minimum one to three years experience in Social Service/Human Service capacity in a hospital, rehab /treatment facility, Skilled Nursing Facility, or community social,health, behavioral health or addictions agency/facility. 
• Addiction Recovery experience a plus.

Minimum Licenses and Certifications

• State licensure preferred LCSW, LSW, or LSWA. 

Required Skills

• Works well with others, organized and efficiency essential.
• Works closely with social service staff , updating resources, networking with agencies. Ability to work independently and with a team. 
• Excellent verbal and written communication skills required.
• Ability to work with community agencies to mobilize resources is required. 
• Flexibility is a must.