Social Worker - MSW Rehab
How have you impacted someone’s life today? At Hackensack Meridian Health our healthcare teams are focused on changing the lives of our patients by providing the highest level of care each and every day. From our hospitals, rehab centers and occupational health teams to our long-term care centers and at-home care capabilities, our complete spectrum of services will allow you to apply your skills in multiple settings while building your career all within New Jersey’s premier healthcare system.
The Social Worker provides social work interventions, counseling and discharge planning services to develop a continuum of care plan that provides for the safe and appropriate transition of the patient from the hospital to the home environment or another health care facility. Utilizes the social work process in determining individual patient needs and the appropriate community resources available to assure continuity of care.
A day in the life of a Social Worker at Hackensack Meridian Health includes:
- Screens referrals according to department policy and procedure for identification of high-risk patients in need of or requesting social service intervention.
- Attends multidisciplinary plan of care meetings & daily care coordination rounds on assigned units.
- Initiates social service intervention within one (1) business day of admission/referral on patients that meet the department's established high-risk criteria.
- Responsible for the completion of the psychosocial assessment and coordination of a safe and appropriate discharge plan in collaboration with other members of the health care team.
- Assess and evaluate post hospital needs through interview and assessment of patient and/or family/significant other and formulate a discharge plan that appropriately addresses the physical, social, economic and emotional needs of the patient. Evaluate needs taking into consideration the patient's current medical problems, past medical, psychosocial and cultural history, and community support system. Evaluate appropriateness of plan and makes revisions as necessary based on ongoing reassessment of patient's needs.
- Utilizing the teach back method, elicits and documents patient's and/or family's/significant other's understanding of, and agreement with the discharge plan.
- Provides limited counseling and crisis intervention services to patient and/or family. Makes available referrals to outside agencies/support groups when appropriate.
- Maintains ongoing communication with the patient, family/significant other, physician, nursing staff, discharge planning nurse, utilization review nurse, and/or other members of the healthcare team concerning the status of the discharge plan and documents such in the medical record.
- Investigates insurance coverage as needed for continuum of care needs and assesses the adequacy of the patient's insurance coverage. Initiates entitlement program referrals when appropriate and needed.
- Communicates verbally and in writing with third party payors as appropriate to obtain all necessary authorizations and facilitate the discharge plan.
- Implements the agreed upon discharge plan by coordinating referrals to the appropriate community agencies, services, programs and facilities.
- Reports identified problems to the assistant director and submit written report according to department policy and procedure.
- Documents all interventions on the Discharge Planning/Social Service Initial Assessment Form and/or the Discharge Planning/Social Work Interdisciplinary Progress Notes in the patient's medical record according to department policy and procedure. Documentation includes:
- Initial assessment, evaluation and tentative discharge plan.
- Ongoing assessment and evaluation with updates/revision in the discharge plan when interventions occur and/or patient status changes.
- Summary of final discharge plan inclusive of the resources to be used post hospitalization along with the patient's and/or family's significant other's understanding of and agreement with the discharge plan.
- Assists and participates in the development and implementation of the department¿s Quality Assessment and Improvement Plan.
- Enters productivity data into data entry system within specified department time frames.
- Completes all annual State and Federal required programs and education.
- Maintains current competency in skills and knowledge of trends and new developments in social work and discharge planning. Assumes responsibility for ongoing professional development and attends continuing education programs and conferences.
- Maintains current knowledge of and an ongoing relationship with staff of available agencies, services, programs and investigates new agency/programs/services as necessary.
- Maintains current knowledge of available community resources/services/agencies and all applicable Hospital Accrediting Agencies, Quality Improvement Organizations and State and Federal requirements regarding discharge planning/social work including Medicare and Medicaid rules and regulations.
- Regularly attends and participates in department staff meetings. Reviews and signs off on minutes for any meeting not attended.
- Performs all other duties as assigned.
Education, Knowledge, Skills and Abilities Required:
- Masters of Social Work degree required.
Education, Knowledge, Skills and Abilities Preferred:
- One year experience in a hospital preferred.
- Bilingual (English/Spanish) preferred.
Licenses and Certifications Required:
- New Jersey social work license required at MSW level.
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
Hackensack Meridian Health (HMH) is a Mandatory COVID-19 and Influenza Vaccination Facility
As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.