Social Worker PACE

Social Worker PACE

Requirements

• Master’s Degree- Social Services – Required
• Licensed Social Worker (LSW) OR Licensed Clinical Social Worker (LCSW)- State Licensing Board – Required
• Auto Insurance- Required
• Driver’s License- Required

Responsibilities

• Develops discharge plans, identifying the post-discharge needs of the patient and target appropriate resources for follow-up care, in collaboration with the patient, family and multidisciplinary care team to make the transition as smooth as possible for patients along the continuum of care.
• Maintains accurate, concise and timely documentation in EPIC and DOC flowsheets for discharge planning.
• Maintains good rapport with internal and external referral sources; facilitates communication with community facilities, agencies, and resources and makes appropriate referrals as needed.
• Documents patient care information and ensures timely and accurate completion of patient care records in accordance with policies and procedures.
• Collaborates with a medical case manager and multidisciplinary treatment team to individualize each patient’s treatment needs in order to achieve defined goals for improved patient outcomes.
• Educates patients and their caregivers about extended care facilities, home health agencies and other resources as appropriate, to transition patients along the continuum of care.
• Assesses social determinates and barriers to discharge from the previously established discharge plan for readmitted patients.
• Performs thorough patient psychosocial assessments to explore the physical, psychological and social aspects of the patient and their conditions, obtains history, and elicits an accurate description of psychosocial needs in order to inform patient treatment plans, in collaboration with patients, their support systems and care team members.

Preferred Qualifications

• 2 years Acute Care Hospital Experience – Preferred
• 2 years Mental Health or related Community Healthcare Experience- Preferred