Social Worker MSW – Hospice, Per Diem – Health First – Melbourne, FL

The Social Worker MSW is responsible and accountable for providing Quality/No Harm, Customer Experience, and Stewardship by coordinating the psychosocial care and services for assigned patients in collaboration with the patient, family, physician, patient care team, and payers. The social worker utilizes advanced psychosocial skills to facilitate the coordination of care through assessment, planning, intervention and evaluation. The social worker promotes and evaluates the effective utilization of resources using current knowledge, awareness of community services, and serving as a role model to achieve optimal clinical and resource outcomes. The Social Worker will promote and effectively utilizes hospital and community resources and achieves optimal outcomes. Primary Accountabilities Assess and document in MIDAS and medical record patient/family needs and collaborates with physicians and staff to identify possible psychosocial related discharge needs. Identifies and documents necessary transitional care referrals (Community resources, home health, skilled nursing, rehab, DME, etc.) utilizing Smart Connect. Assists with coordination of referrals for post acute services as appropriate in a timely manner. Communicating with the patient/caregiver and physician on issues related to payer or financial issues. Coordinates and documents complex discharge plans. Collaboratively determines desired discharge goals and communicates all discharge plans and options to patient/family, physicians and staff members.Collaborates with RN Case Manager, staff RN, ancillary staff and physicians facilitating continuity of care for the patient. Identifies “at risk” patient populations and/or strengths of patient/family support systems on admission. Conducts psychosocial assessment to screen for patients/families at risk for crisis, abuse, financial or environmental issues. Provides therapeutic/crisis intervention counseling with patients and families as needed. Provides supportive services for End of Life Issues, Terminal Care and Bereavement issues. Coordination of Adoptions with patients and families. Provides counseling and researches placement alternatives for substance abuse, mental health, homeless and indigent patients. Facilitates and participates in transfer of Baker Act and Marchman placements to mental health facilities. Provides therapeutic interventions with patients and families as needed. Facilitates referrals for post-discharge psychosocial and therapeutic needs Identifies system/process breakdowns and improvement opportunities and documents according to the Performance Improvement plan. Assures compliance with regulatory standards of care at both the state and federal levels.

MSW degree from a Council on Social Work accredited school or Master’s degree in related field with appropriate experience. LCSW Eligible and obtained within five (5) years of employment. Three (3) years of previous social work experience preferred. Case Management experience preferred Acute Care experience preferred.Must hold current AHA BLS healthcare provider completion card Demonstrated computer experience.

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