Social Worker, MSW

Job Summary:

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.

TECHNICAL STANDARDS

Essential Functions: Defined as duties specific to the job, that, if removed, would change the entire purpose of the job; to include the Essential Physical Demands and Essential Working Conditions of this position.

• Core Essential Functions:

• Regular, consistent, on-site, and timely attendance.

• PROFESSIONAL ROLE

• Maintains professional and technical knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies.

• 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.

• Protects patients and employees by adhering to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations.

• Documents patient care services by charting in patient and department records.

• Maintains continuity among nursing teams by documenting and communicating actions, irregularities, and continuing needs using Nurse Knowledge Exchange techniques.

• Maintains patient confidence and protects operations by keeping information confidential.

• Implements standard work, clinical protocols and patient care pathways.

• Ensures safe and effective transitions of care that help to promote positive health care outcomes for Excela Health patients.

• CLINICAL ROLE

• 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.

• 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.

• Initiates care coordination strategies that are evidence-based and outcome focused.

• Implements standard work, clinical protocols and patient care pathways.

• Identifies patient care requirements by establishing personal rapport with potential and actual patients, and other persons in a position to understand care requirements.

• 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.

• Promotes patient's independence by establishing patient care goals; teaching patient/family to understand condition, medications, and self-care skills; answering questions.

• Maintains safe and clean working environment by complying with procedures, rules and regulations; calling for assistance from health care support personnel.

• 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.

• Assures care coordination that takes into account patients' values, needs, preferences and their choice to self-direct care.

• LEADERSHIP ROLE

• 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.

• 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.

• Facilitates the flow of care to expedite appropriate discharge and prevent readmissions.

• Assumes the leadership role in achieving outcomes and making the health system work for the patient.

• Brings access, understanding and knowledge of the community and the resources to support management of chronic illness.

• Resolves patient problems and needs by utilizing multidisciplinary team strategies.

• 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.

• Contributes to team effort by accomplishing related results as needed.

• Implements effective care coordination strategies that are evidence-based and outcome focused.

• 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)"

• Specialty Essential Functions:

• Plans, organizes, and coordinates plan of care on assigned patients.

• Completes accurate, timely, and appropriate documentation of interventions to execute plan of care.

• Communicates plan of care to members for the health care team via attendance at Collaborative Care rounds, concurrent documentation and verbal communication.

• Evaluates and projects discharge planning needs and coordinates post-acute care needs of patient in assigned case load.

• Demonstrates knowledge/application of acute care criteria.

• Coordinates post-hospital needs in a timely and effective manner.

• Identifies, tracks and trends Avoidable/Delay Days in Midas system.

• Makes referrals to CRM Manager or designee for complex cases.

• Thorough knowledge of social work principles, techniques and practices and their application to complete patient/family/organizational needs.

• Provides therapeutic goal-directed counseling services to patients and their families on a limited basis in order to facilitate the discharge planning process.

• Applies advanced interpersonal skills in negotiating appropriate plan of care needs for assigned patient population.

• Acts as a resource/consultant to internal customers for extensive knowledge of community resources and expertise in accessing social/community systems.

• Reviews the laws and regulations that influence the practice of social work. Has working knowledge of Advanced Directives, HIPAA, and health care proxy formats.

• Marginal Functions: Defined as duties that are not essential in nature and do not take a considerable amount of time to complete (less than 10%).

• Performs other duties as required.

• Required Skills and Knowledge: Minimum level of education, skills and abilities necessary in performing the job.

Education:

• Master's in Social Work

Certification / Licensure / Regulation:

• Act 33 with renewal

• Act 34 with renewal

• Act 73 FBI Clearance

Prior Experience:

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

Other Skills and Abilities:

• Knowledge of Payor/Insurance Benefits

• Functional Skills on PC and Related Software (Microsoft Office)

• Knowledge of basic Office Equipment such as copier, fax machine, etc.

• Strong leadership ability, independent thinking and decision-making ability; analytical problem solving skills, sound judgment; excellent oral and written communication skills, must be able to function in a team environment.

• Ability to communicate with all members of the health care team

• Independent thinking and decision-making ability

• Ability to multi-task and prioritize assignments

• Familiarity with InterQual Level of Care criteria. Outstanding interpersonal communication skills. Flexibility/prioritization skills. Able to meet attendance / scheduling requirements.

Preferred Factor:

These are job related enhancements that are preferred or would benefit the performance outcome of the job but are not essential or required for the job to exist.

• LSW, Case Management Certification, experience in palliative care

The above job descriptive information is intended to describe the general nature and level of work being performed by individuals assigned to this job. This is not intended to be an exhaustive list of all duties and responsibilities, as an employee may be assigned other duties other than described in this document.

• Essential Working Conditions:

Constantly = (5 1/2 to 8 hours or more) or 200 reps/shift

Occasionally = (1/4 to 2 1/2 hours) or 2 - 32 reps/shift

Frequently = (2 1/2 to 5 1/2 hours or more) or 32 - 200 reps/shift

Rarely = (Less than 1/4 hours) or < 2 reps/shift

Sedentary Work -

Exerting up to 10 pounds of force occasionally.

Light Work -

Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly.

Medium Work -

Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force occasionally.

Heavy Work -

Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly.

Very Heavy Work -

Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds or force frequently, and/or in excess of 20 pounds of force constantly to move objects.

Working Conditions:

Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines

Never

Extreme Noise (> 85 dB)

Mechanical Hazards

Use of Vibrating Tools

Operates Vehicle

Operates Heavy Equipment

Use of Lifting/Transfer Devices

Rotates all shifts

Extreme Cold

Extreme Heat

Heights

10 - 12 hour shifts

Overtime (more than 8 hrs. /shift, 40 hours/week)

Rarely

On Call

Confined Spaces-Cramped Quarters (Labeled)

Constantly

8 hour shifts

Protective Equipment:

Never

Respirator-Breathing Equipment

Eye

Head (hard hat)

Hearing

Hands

Feet, Toes

Body

Occupational Exposures:

Never

Solvents

Paints (direct use of)

Dust (Sanding)

Ethylene Oxide

Cytotoxic Drugs (Chemo)

Chemicals (direct use of)

Mists

Radiation

Ionizing Radiation

Lasers

Rarely

Wax Stripper (direct use of)

Blood and Body Fluids

Occasionally

Latex (Rubber, erasers, balloons, gloves, rubber bands, etc.)

VII. Essential Physical Conditions:

Marginal

Frequently = (2 1/2 to 5 1/2 hours or more) or 32 - 200 reps/shift

Essential

Occasionally = (1/4 to 2 1/2 hours) or 2 - 32 reps/shift

Constantly = (5 1/2 to 8 hours or more) or 200 reps/shift

Rarely = (Less than 1/4 hours) or < 2 reps/shift

Physical Demands:

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Never

Climbing Ladders

Kneeling

Use of Forceful Hand Grasp

Rarely

Squatting (Crouching)

Climbing Stairs

Occasionally

Walking

Bending (Stooping)

Keyboard/Computer Operation

Standing

Fine Finger Manipulation

Hand / Arm Coordination

Pushing / Pulling

Frequently

Sitting

Sensory Requirements:

Constantly

Seeing Near-with Acuity

Feeling (Sensation)

Color Vision

Over Shoulder Work:

Never

Pulling or Pushing Objects Overhead

Rarely

Reaching Above Shoulder Level

Lifting: floor to standing position:

Never

20 - 29 pounds

30 - 49 pounds

50 pounds

50 pounds

Rarely

10 - 19 pounds

Lifting: waist to shoulder level:

Never

10 - 19 pounds

20 - 29 pounds

30 - 49 pounds

50 pounds

50 pounds

Lifting: shoulder to overhead:

Never

10 - 19 pounds

20 - 29 pounds

30 - 49 pounds

50 pounds

50 pounds