Care Transitions Social Worker

GENERAL SUMMARY:

The Care Management Social Worker is responsible for collaborating with health care team members to identify and plan for the complex and problematic psychosocial needs of the patient and family. Assists patients and families in adjusting to the demands of chronic health care needs across the continuum. Serves as a resource to the inter-disciplinary team. Provides support and case consultation to other case management team members when complex issues arise.

PRINCIPAL JOB FUNCTIONS:

• Commits to the mission, vision, beliefs and consistently demonstrates our core values.
• Completes case management assessments; determines priorities for case management intervention

and differential treatment needs of patient's and families; documents assessment, plans and

interventions based upon departmental standards.

• Utilizes knowledge of high-risk indicators to identify all forms of family violence; understands impact

of different types of chronic illness on the patient and family.

• Provides supportive counseling to patients and families to enhance coping mechanisms.

Provides crisis intervention services to patients, families and staff; assists patients, families and staff in

problem solving and conflict resolution.

• Serves as a resource to the inter-disciplinary team and Care Management Discharge Specialists in

meeting complex needs of patients and families throughout the process of discharge planning.

• Partners with Care Management Discharge Planning staff to assist in identification and resolution of

complex and problematic discharge planning issues.

• Maintains professional relationships and communicates effectively with other members of the inter

disciplinary team.

• Initiates communication with peers about clinical practice issues.

EDUCATION AND EXPERIENCE:

Masters degree in Social Work (MSW) from a School of Social Work OR Masters degree in Counseling required. Current certification as a Licensed Mental Health Practitioner (LMHP) by the State of Nebraska preferred. Prior case management experience desired.