SOCIAL WORKER - MSW

The Social Worker plans, organizes, and directs the clinical case management functions of assigned patient population under the direction of the Nurse Care Manager. This includes completing clinical and biopsychosocial assessments on all assigned cases to determine appropriate utilization of facility resources and thereby ensuring timely, effective, and safe discharges. Assumes a leadership role within the health care team by facilitating and attending Collaborative Care Rounds on assigned units. Work may involve in-depth assessment of family dynamics and needs which requires comprehensive working knowledge of community resources to direct positive discharge outcomes.
Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements. Recognizes the necessity of taking ownership of one’s own motivation, morale, performance and professional development. Strives for behavior consistent with being committed to Excela’s missions, vision and values.


1. Regular, consistent, on-site, and timely attendance.
2. PROFESSIONAL ROLE
a. Maintains professional and technical knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
b. Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following system / hospital and nursing division's philosophies and standards of care set by state board of Professional Occupations and Affairs, and other governing agency regulations along with the specific organizations code of conduct.
c. Protects patients and employees by adhering to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations.
d. Documents patient care services by charting in patient and department records.
e. Maintains continuity among nursing teams by documenting and communicating actions, irregularities, and continuing needs using Nurse Knowledge Exchange techniques.
f. Maintains patient confidence and protects operations by keeping information confidential.
g. Implements standard work, clinical protocols and patient care pathways.
h. Ensures safe and effective transitions of care that help to promote positive health care outcomes for Excela Health patients.
3. CLINICAL ROLE
a. Assesses, plans, implements coordinates, and monitors and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes.
b. Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes. Provides crisis management for clients; makes linkages for interventions as appropriate.
c. Initiates care coordination strategies that are evidence-based and outcome focused.
d. Implements standard work, clinical protocols and patient care pathways.
e. Identifies patient care requirements by establishing personal rapport with potential and actual patients, and other persons in a position to understand care requirements.
f. Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families. Provides assistance to improve people's overall quality of life and meet people's individual needs through Conflict Resolution & Reconciliation, Social Work and Behavior Analysis. Along with addressing the personal and social issues that affect people's mental well-being.
g. Promotes patient's independence by establishing patient care goals; teaching patient/family to understand condition, medications, and self-care skills; answering questions.
h. Maintains safe and clean working environment by complying with procedures, rules and regulations; calling for assistance from health care support personnel.
i. Demonstrates competencies of clinical reasoning and critical-thinking skills for managing complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally competent care.
j. Assures care coordination that takes into account patients' values, needs, preferences and their choice to self-direct care.
4. LEADERSHIP ROLE
a. Puts the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time.
b. Effectively manages transitions involving comprehensive planning, targeted outreach and the timely transfer of information between parties critical to the transition. Manages transitions of care effectively as one of the critical components to reducing re-admissions and poor health outcomes.
c. Facilitates the flow of care to expedite appropriate discharge and prevent readmissions.
d. Assumes the leadership role in achieving outcomes and making the health system work for the patient.
e. Brings access, understanding and knowledge of the community and the resources to support management of chronic illness.
f. Resolves patient problems and needs by utilizing multidisciplinary team strategies.
g. Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team continuous quality improvement and problem-solving methods.
h. Contributes to team effort by accomplishing related results as needed.
i. Implements effective care coordination strategies that are evidence-based and outcome focused.
j. Seeks role as chair, co-chair, and lead for CQI projects or shared governance, council, committees or work groups.
“Ability to perform the Essential Functions on the Physical Conditions chart; and the ability to perform the Essential Functions on the Working Conditions chart (see attached charts)”


1. Plans, organizes, and coordinates plan of care on assigned patients.
a. Completes accurate, timely, and appropriate documentation of interventions to execute plan of care.
b. Communicates plan of care to members for the health care team via attendance at Collaborative Care rounds, concurrent documentation and verbal communication.
c. Evaluates and projects discharge planning needs and coordinates post-acute care needs of patient in assigned case load.
2. Demonstrates knowledge/application of acute care criteria.
a. Coordinates post-hospital needs in a timely and effective manner.
b. Identifies, tracks and trends Avoidable/Delay Days in Midas system.
c. Makes referrals to CRM Manager or designee for complex cases.
3. Thorough knowledge of social work principles, techniques and practices and their application to complete patient/family/organizational needs.
a. Provides therapeutic goal-directed counseling services to patients and their families on a limited basis in order to facilitate the discharge planning process.
b. Applies advanced interpersonal skills in negotiating appropriate plan of care needs for assigned patient population.
c. Acts as a resource/consultant to internal customers for extensive knowledge of community resources and expertise in accessing social/community systems.
4. Reviews the laws and regulations that influence the practice of social work. Has working knowledge of Advanced Directives, HIPAA, and health care proxy formats.


• Case management/social work within the last two years; prior work experience in acute care; internship in acute care