SOCIAL WORKER WEEKEND MSW

Job description

Essential Job Functions: - Assesses, plans, implements, coordinates, monitors, and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes. - Completes patient assessments to identify barriers to discharge with a focus on social determinants of heath, patient’s ability for self care, or any potential post-hospital services that may be required at discharge. - Identifies any psychosocial, clinical, cultural, spiritual, or financial barriers that may impede a safe effective transition from the hospital. - Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes. - Initiates care coordination strategies that are evidence-based and outcome focused. - Collaborates with the multidisciplinary team to formulate a safe discharge team. - Utilizes the readmission risk tool to identify barriers to effective discharge plan. - Identifies patient care requirements by establishing personal rapport with patients, families, and caregivers. - Establishes a compassionate environment by providing emotional, psychological, and spiritual supp...