Principal Responsibilities and Tasks

The following statements describe the general work performed in this role. It is not an exhaustive list of all duties that may be performed.

1. Completes psychosocial assessments, incorporating the results of screening tools administered to develop an appropriate plan(s) of care.

2. Autonomously proposes & executes safe, appropriate, and timely plan of care and/or discharge plan patients, families, and multidisciplinary healthcare team. Seeks assistance from a supervisor and/or interdisciplinary team as needed.

3. Administers crisis intervention, as necessary, and demonstrates expert use of social work skills within the individual's specialty to provide trauma informed care related to the patient's social determinants of health.

4. Assesses the biopsychosocial status of identified individuals in the home or other settings initiating appropriate community referrals in addition to providing support services to individuals, families, and caregivers. Community referrals include, but are not limited to, provision of nutrition, prescription assistance, transportation, housing and rent assistance, and custodial in-home care.
5. Interviews individuals, families, and caregivers for personal, social, and environmental history. Evaluate social functioning particularly as it relates to medical problems.

6. Evaluates effectiveness of patients' response to social work intervention, individual social work practice, and programs within the organization. Participates in performance improvement initiatives.

7. Shares resources with patients, families, and co-workers. Maintains a current list of relevant community resources. Demonstrates flexibility and creativity when identifying appropriate community resources for patients and their families.

8. Maintains a working knowledge of relevant medical, cultural, social, regulatory, legal, and other issues that could impact patient care. Conducts chart reviews to gain an understanding of past referrals and utilization of services. Coordinates and documents appropriate referrals and keeps patient, family, and care team informed of referrals made.

9. Serves as a liaison with outside agents and other departments to improve coordination and consultation of patients' care, while obtaining appropriate Releases of Information and maintaining confidentiality as it relates to HIPAA; Assess financial security with consideration of diagnosis, prognosis and medical necessities. Facilitate and manage referral to agencies for financial assistance if indicated.
10. Educate on chronic disease self-management, including instruction on coping strategies, planning, goal setting, behavior modeling, problem-solving techniques, and decision making related to managing chronic conditions

11. Conducts individual and group education sessions. Serves as an educational and training resource to SW I & SW II within their practice area.

12. Acts as a liaison between the patient, family, treatment team, and other departments in service of furthering equitable patient-centered within the healthcare delivery system.
13. Recognizes and identifies systemic challenges impacting individual patients and the impact to their health, well-being, and access to care. Works to empower change to address equity within the healthcare and community systems in which the patients exists. Explores strategies to reduce resource consumption for target populations; implements and evaluates outcomes.

14. Performs departmental administrative duties; Able to adhere to communicated care management productivity metrics, including caseload, engagement volume, and time to closure.

15. Completes all specific job tasks within their assigned department as outlined by supervisor.