Job Description

Coordinates the care and services of select patients. Intervenes with patients who have complex psychosocial and discharge planning needs. Conducts detailed psychosocial assessments and coordinates with community resources and supportive counseling. Offers crisis interventions to patients and families with psychosocial needs and facilitates transition of care for high risk patients facing barriers to care.

Responsibilities:

• Manages all aspects of discharge planning for assigned patients in order to ensure a timely discharge and provide appropriate connection with post-discharge care providers.

• Works with families exhibiting complex family dynamics.
• Communicates with interdisciplinary team regarding the discharge planning status of all patients that are referred.
• Educates patient, family and physician regarding post-acute options and addresses freedom of choice and financial concerns.
• Conducts initial and ongoing psychosocial assessment and interventions and makes treatment recommendations to engage patients and families in adherence to the treatment plan by reducing or eliminating the social, psychological, financial, behavioral and regulatory barriers to successful medical outcomes.
• Serves as a resource person to provide counseling and intervention related to treatment decisions and end-of-life issues.
• Advocates for patient and family by providing intervention in cases involving child abuse and neglect, domestic violence, elderly abuse, institutional abuse and sexual assault.
• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system and community.
• Meets core social work competencies and adheres to regulations.
• Remains current with regulations which impact the care of patients and regulatory compliance.
• Promotes individual, professional growth and development and meets mandatory and continuing education requirements.
• Supports department-based goals which contribute to the success of the organization.
• Serves as a preceptor, mentor, and resource to less experienced staff and represents the department on committees.

• Other duties as assigned.

Education:

• Master's Degree in Social Work or Masters of Science in Social Administration (MSSA).

Certifications:

• Current state licensure as a Social Worker.
• Eligible licensure includes LSW, LISW, LISW-S
• For Homecare and Hospice, eligible licensure includes LSW, LISW or LISW-S.
• Care Management Department : Certification as a Case Manager within one year of eligibility from an approved professional organization preferred
• Basic Life Support (BLS) through American Heart Association (AHA) required upon hire
• For Homecare and Hospice field staff only: Valid Ohio Driver’s license upon hire; per policy 8-175 thereafter.
• For Homecare and Hospice field staff only: Proof of automobile insurance coverage with $100,000/$300,000 coverage, upon hire; per policy 8-175 thereafter.

Complexity of Work:

• Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.

Work Experience:

• Minimum of 3 years’ experience in healthcare system to include exposure to and experience in pre acute and post-acute care preferred.
• Hospital Social Work experience preferred.
• Home Care and/or Hospice Social Work experience is preferred for candidates applying to those roles.
• Knowledge of community resources preferred.
• Excellent communication and negotiation skills necessary to work collaboratively with multidisciplinary teams for optimal outcomes.

• Demonstrated ability to work independently as well as with teams.
• Must be flexible, open-minded and adaptable to change.

Physical Requirements:

• Ability to perform work in a stationary position for extended periods.
• Ability to communicate and exchange accurate information
• Ability to work with physical records, such as retrieving and filing. Ability to operate a computer and other office equipment.
• Ability to travel throughout the hospital system.
• Requires normal or corrected hearing and vision to normal range.
• In some locations ability to lift up to 10 pounds

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment as required for procedures.

Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.

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