Coordinates and facilitates care plans for patients and families across the continuum of care from inpatient to outpatient settings. Provides psycho-social assessments, leads support groups, and mediates communication between medical staff and families to ensure effective treatment compliance.
Requirements summary
Requires a Master's degree in Social Work and a valid LMSW or LISW license. While no previous experience is required, one year of experience in a hospital setting and bilingual skills in Spanish are preferred.
Job Summary Coordinates and facilitates the plan of care for the applicable department and interdisciplinary health care team.
Responsible for advising the medical staff of available services to ensure delivery of care is provided in the most cost-effective manner in the least restrictive environment.
Leads treatment team in the delivery and adjustment of services across the continuum of care (inpatient to outpatient).
Ensures patient/family successful completion of the care plan with continuous supervision and monitoring.
Implements corrective action to reduce noncompliance by assessment, education, counseling and modifications to the plan of care.
Coordinates and adjusts care plans across the continuum of care (inpatient to outpatient).
Essential Functions All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health.
Serve with compassion.
Be the difference Provides leadership with the flow of information between team members on inpatient and outpatient units and in addressing issues related to poor medical compliance and the development of a correct plan.
Leads support groups and family education conferences.
Promotes community awareness and education related to specialty area issues.
Facilitates community requests for education information.
Mentors' students and other staff as appropriate.
Assists leadership in ensuring excellent patient care services by coordinating education and outreach services, leading quality improvement initiatives, and actively serving on hospital committees.
Attends and participates in meetings as required.
Enhances professional growth and development through professional affiliations, participation in educational programs, in-services, workshops and review of literature.
May facilitate daily hospital-based interdisciplinary team meetings to include clinical case conference of patients on service, team debriefing/self-care, team problem-solving and conflict resolution.
Provides psycho-social assessment of newly diagnosed patients as related to their health problems.
Performs ongoing evaluation/assessment of patient and family, as applicable.
Develop plan of care based on the evaluation/assessment.
Completes assessment of patient/family financial resources as related to the provision of the plan of care.
Make appropriate interventions for financial assistance.
Makes recommendations to medical staff based on evaluations/assessments, as needed.
Uses professional background and skills to assist with complex family meetings focused on clarification of the goals for care, the plan of care, and conflict management.
Lead family planning discussions.
Facilitates patient assistance services including referrals to appropriate community organizations.
Works with medical staff to ensure family's strengths and weaknesses are considered when developing the comprehensive care plan.
Evaluates plans and services and makes recommendations for the improvement of services and the promotion of patient and family centered care.
Participates in scheduled department meetings.
Responsible for assuring patient/family's understanding of treatment plan and expectation regarding medical care and follow up.
Facilitate effective coping for both patients and their families in the hospital setting.
Demonstrates a working knowledge of the impact of patient's condition and assists patient/family with adjustment concerns.
Demonstrates a working knowledge of the impact of patient's condition on family functioning and assists patient/family in the development of appropriate mechanisms for coping.
Supervises patient/family compliance and makes recommendations for the appropriate follow up.
Completes required documentation including letters, forms, chart notes, applications, etc.
Serves as patient advocate with third party payors and other providers of services as needed.
Demonstrates working knowledge of community resources and mechanisms.
Arrange referrals to appropriate community services and resources, as needed.
Facilitates communication among those involved with the patient's care to ensure effective collaboration.
Mediates between patient/family and medical staff addressing issues of concern and establishes open communication through which the patient/family can ask questions, voice concerns and maintain active participation in their health care plan.
Facilitates comprehensive individual, marital and family counseling as needed.
Participates in program evaluations, CQI and other performance improvement measures as appropriate.
Provides input and carries out department goals and objectives.
Provides input into the formulation of, and revision to, departmental policies and procedures.
Monitors the continuum of care for the inpatient length of stay and makes recommendations to maximize the provision of services provided in a timely fashion.
Performs other duties as assigned.
Supervisory/Management Responsibilities This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements Education - Master's degree in Social work or related field of study.
Experience - No previous experience required.
One (1) year of experience in a hospital setting preferred.
In Lieu Of NA Required Certifications, Registrations, Licenses LSW - Licensed Social Worker - LLSW Currently licensed as a Licensed Master Social Worker (LMSW) by the state Board of Social Work Examiners or currently licensed as a Licensed Independent Social Worker (LISW) by the state Board of Social Work Examiners.
LISW (Licensed Independent Masters Social Worker) Preferred
Knowledge, Skills and Abilities
Bilingual in Spanish- Preferred Work Shift Day (United States of America) Location Ctr For Family Med - Oconee Facility 1064 Oconee Memorial Hospital Department 10646801 Clinic Nursing General Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health. Prisma Health is the largest not-for-profit health organization in South Carolina, serving more than 1.2 million patients annually. Our 32,000 team members are dedicated to supporting the health and well-being of you and your family. Our promise is to: Inspire health. Serve with compassion. Be the difference.
