Employment Type:

Part time

Shift:

Rotating Shift

Description:

Job Title Social Worker (MSW) POOL

Operating Unit Nazareth Hospital

Department Coordinated Care Evaluation Date

FLSA Status Non-Exempt Colleague's Name

Reports To Director of Care Coordination Colleague's Signature

Approved By Elaina Watts Evaluator's Name

Effective Date 6/1/2016 Evaluator's Signature

General Responsibilities

"In collaboration with Care Coordination staff, this position is directly involved in the process of assessment, planning, facilitation, and advocacy for options and services to meet individual patient’s health care needs. Through communication and identification of available resources, participates in the promotion of quality outcomes, patient satisfaction, and cost-effective care delivery. This position reports to the Director of Care Coordination.

Schedule: This position has weekend rotation. Case Load: 1:40 Ratio"

Essential Duties Performance Rating

(1 – 5)

1 Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

Comments:

2 Participates constructively in PI activities in the department

Comments:

3 Recognizes special needs/concerns of populations served and adjusts communication accordingly, i.e., language barrier, diminished hearing, concrete terms, etc.

Comments:

4 "Interviews patients/significant others within one working day of Utilization Management Nurse, ED Case Manager, Care Transition Nurse, or other referral to obtain data on personal, social, medical, emotional, cultural, and religious history in order to delineate problems requiring Social Work intervention and to plan appropriate services.

"

Comments:

5 Collaborates with the Care Coordination staff and multidisciplinary team members regarding discharge planning and arranges for needed care in the home or an alternate setting.

Comments:

6 Provides support and counseling to patients/families experiencing and/or anticipating issues to adjusting to illness, catastrophic diagnoses, changes in living situations and bereavement. Establishes a plan. Documents interventions and outcomes as required in the electronic record.

Comments:

7 Consults, assesses, refers, coordinates interventions in cases of suspected or actual situations of child or abuse and neglect or other forms of domestic violence and/or sexual abuse.

Comments:

8 Actively participates and provides pertinent information in multidisciplinary rounds on assigned patients.

Comments:

9 Provides advanced directive education, counseling and support as needed.

Comments:

10 Completes appropriate assessments for assigned patients to identify gaps in care, develop goals, and facilitate interventions and resources.

Comments:

11 Assists patients/families to complete applications for Medicaid benefits.

Comments:

12 Manages the placement process into long term care facilities. Reviews financial resources for long term placement and provides education to the patient/family.

Comments:

13 Serves as the lead in obtaining financial and other resources for patients and families in need.

Comments:

14 Facilitates patient/family and provider meetings as necessary to develop and plan strategies related to psychosocial and economic issues, particularly those related to care progression and transition. May act as the liaison between patients/families and all providers of care within and external to the organization on social issues.

Comments:

15 Serves as the lead in obtaining legal guardianship and competency determinations. Completes and disseminates all necessary legal and clinical documentation as required. Documents in the patient record according to department policies and procedures.

Comments:

16 Serves as the liaison for interagency collaboration.

Comments:

17 Works collaboratively with the multidisciplinary team to identify patients at risk for rehospitalization, and mediates barriers to successful discharge plan.

Comments:

18 Prepares and maintains individual patient and departmental records according to department, federal and state regulations; completes statistical information and prepares correspondence as needed.

Comments:

19 Adheres to Discharge Planning and Organizational policies and standards as well as standards from external regulatory agencies and accrediting bodies, e.g., JCAHO, Department of Public Health, etc.

Comments:

20 Conducts support groups for targeted populations

Comments:

21 Other duties as needed and assigned by the manager.

Comments:

22 Adheres to applicable Federal, State, and local laws and regulations, Trinity Health’s Integrity and Compliance Program and Code of Conduct, as well as other policies and procedures.

Comments:

Average Score

Job Title Social Worker (MSW) POOL

Operating Unit Nazareth Hospital

Department Coordinated Care Evaluation Date

FLSA Status Non-Exempt Colleague's Name

Reports To Director of Care Coordination Colleague's Signature

Approved By Elaina Watts Evaluator's Name

Effective Date 6/1/2016 Evaluator's Signature

General Responsibilities

"In collaboration with Care Coordination staff, this position is directly involved in the process of assessment, planning, facilitation, and advocacy for options and services to meet individual patient’s health care needs. Through communication and identification of available resources, participates in the promotion of quality outcomes, patient satisfaction, and cost-effective care delivery. This position reports to the Director of Care Coordination.

Schedule: This position has weekend rotation. Case Load: 1:40 Ratio"

Essential Duties Performance Rating

(1 – 5)

1 Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

Comments:

2 Participates constructively in PI activities in the department

Comments:

3 Recognizes special needs/concerns of populations served and adjusts communication accordingly, i.e., language barrier, diminished hearing, concrete terms, etc.

Comments:

4 "Interviews patients/significant others within one working day of Utilization Management Nurse, ED Case Manager, Care Transition Nurse, or other referral to obtain data on personal, social, medical, emotional, cultural, and religious history in order to delineate problems requiring Social Work intervention and to plan appropriate services.

"

Comments:

5 Collaborates with the Care Coordination staff and multidisciplinary team members regarding discharge planning and arranges for needed care in the home or an alternate setting.

Comments:

6 Provides support and counseling to patients/families experiencing and/or anticipating issues to adjusting to illness, catastrophic diagnoses, changes in living situations and bereavement. Establishes a plan. Documents interventions and outcomes as required in the electronic record.

Comments:

7 Consults, assesses, refers, coordinates interventions in cases of suspected or actual situations of child or abuse and neglect or other forms of domestic violence and/or sexual abuse.

Comments:

8 Actively participates and provides pertinent information in multidisciplinary rounds on assigned patients.

Comments:

9 Provides advanced directive education, counseling and support as needed.

Comments:

10 Completes appropriate assessments for assigned patients to identify gaps in care, develop goals, and facilitate interventions and resources.

Comments:

11 Assists patients/families to complete applications for Medicaid benefits.

Comments:

12 Manages the placement process into long term care facilities. Reviews financial resources for long term placement and provides education to the patient/family.

Comments:

13 Serves as the lead in obtaining financial and other resources for patients and families in need.

Comments:

14 Facilitates patient/family and provider meetings as necessary to develop and plan strategies related to psychosocial and economic issues, particularly those related to care progression and transition. May act as the liaison between patients/families and all providers of care within and external to the organization on social issues.

Comments:

15 Serves as the lead in obtaining legal guardianship and competency determinations. Completes and disseminates all necessary legal and clinical documentation as required. Documents in the patient record according to department policies and procedures.

Comments:

16 Serves as the liaison for interagency collaboration.

Comments:

17 Works collaboratively with the multidisciplinary team to identify patients at risk for rehospitalization, and mediates barriers to successful discharge plan.

Comments:

18 Prepares and maintains individual patient and departmental records according to department, federal and state regulations; completes statistical information and prepares correspondence as needed.

Comments:

19 Adheres to Discharge Planning and Organizational policies and standards as well as standards from external regulatory agencies and accrediting bodies, e.g., JCAHO, Department of Public Health, etc.

Comments:

20 Conducts support groups for targeted populations

Comments:

21 Other duties as needed and assigned by the manager.

Comments:

22 Adheres to applicable Federal, State, and local laws and regulations, Trinity Health’s Integrity and Compliance Program and Code of Conduct, as well as other policies and procedures.

Comments:

Average Score

In collaboration with Care Coordination staff, this position is directly involved in the process of assessment, planning, facilitation, and advocacy for options and services to meet individual patient’s health care needs. Through communication and identification of available resources, participates in the promotion of quality outcomes, patient satisfaction, and cost-effective care delivery. This position reports to the Director of Care Coordination.

Schedule: This position has weekend rotation. Case Load: 1:40 Ratio

This position requires a Master's of Social Work but does not need to be licensed.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran