Lic Soc Worker

• Conduct psychosocial assessments to identify patient and family needs related to hospitalization, discharge planning, and community resources.
• Develop and implement social work service plans focused on resource needs, support systems, and care transitions.
• Coordinate discharge planning and care transitions, including referrals to appropriate providers, to ensure safe and timely discharge to home or post-acute care settings.
• Manage socially complex cases involving barriers to discharge such as homelessness, behavioral health concerns, substance use, guardianship, abuse/neglect, or lack of caregiver support.
• Collaborate with community agencies and legal resources to address complex social determinants of health and ensure safe discharge planning.
• Provide crisis intervention and emotional support for patients and families during acute medical events, trauma, or end-of-life situations.
• Facilitate family meetings to clarify goals of care and address psychosocial concerns.
• Perform case management and resource navigation, including financial assistance, insurance benefits, transportation, and community programs.
• Advocate for patient rights and assist with advance directives and healthcare decision-making support.
• Ensure compliance with CMS Conditions of Participation for discharge planning and maintain HIPAA standards for confidentiality.
• Participate in interdisciplinary rounds and care conferences to communicate patient needs and advocate for appropriate services.
• Provide culturally competent care, respecting diversity and incorporating cultural values and family-centered practices.
• Document according to departmental standards and regulatory requirements to assure compliance and continuity of care.
• Participate in performance improvement activities, maintain educational records, and demonstrate competency.
• Attend departmental meetings, in-services, and assist with orientation of new personnel as assigned.

None flagged.