Social Worker

• Provides social work services to patients, their families and/or significant others through counseling, emotional support, assisting with environmental needs, crisis intervention, and group leadership.
• Complete a comprehensive assessment to develop a safe, realistic discharge plan of care appropriate for the patient, in consideration of psychosocial, emotional, and financial needs, and in collaboration with the care management team and documents in the electronic medical record.
• Assess changes in the physician’s plan of care and any impact on the discharge plan.
• Reviews discharge plan on an ongoing basis and communicates any changes to the appropriate party. Documents the discharge plan in the electronic medical record.
• Identifies potential problems with post-discharge care and/or initiates early referrals to promote proper utilization of hospital resources and timely transfer to the appropriate level of care.
• Explore and collaborate with resources within the hospital and community to meet defined patient needs and refers patients and/or families to resources including but not limited to income assistance programs, transportation services, meal assistance, etc.

Social Worker providing support and resources to patients and families in a healthcare setting

Social Worker, BSW

Social Worker providing support services to patients and families in a healthcare setting. Collaborating with medical teams for comprehensive care and addressing psychosocial needs.

• Provides psychosocial services to patients treated by the facility
• Works with the health care team to promote positive adjustment, rehabilitation and improved quality of life for patients
• Supports Fresenius Kidney Care (FKC) commitment to Quality Assessment and Improvement

Entry level MSW supporting patients with psychosocial services in dialysis care

Master Social Worker – MSW

Entry level MSW providing psychosocial services to dialysis patients while working within an interdisciplinary healthcare team. Focusing on quality of life improvements and patient support.

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Assist in ensuring compliance with CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements.
• Perform psychological, social and economic care management interventions for members with severe/persistent mental or emotional disorders.
• Perform telephonic behavioral health comprehensive assessments of members’ environmental, behavioral, psychological, economic and social factors.
• Assist in the development of individualized and culturally sensitive care plans in collaboration with the member’s assigned CM, identifying problems, interventions, barriers and goals.
• Performing telephonic re-assessments, care plan revisions and evaluating the effectiveness of the members’ care plan.
• Member of the ICT for members with SDOH and BH needs and participates in ICT meetings when appropriate.
• Recognizes early signs of a members’ decompensation that requires immediate case management intervention that promotes and motivates compliance with treatment plan.
• Serves as an additional point of contact during transitions of care.
• Co-manages member cases with the CM to address psycho-social, economic and cultural issues that may impact the members’ care needs.
• Serves as a primary socio-economic resource for the D-SNP Care Management Team.
• Documents in the members’ case accurately and timely to ensure coordination of the members’ care needs.
• Adheres to all CMS, Code of Federal Regulations, local/state/national regulatory requirements and guidelines as well as those outlined within the MOC.
• Collaborate with all members of the interdisciplinary care team to facilitate appropriate community resource assistance for members with identified needs.
• Screens, identifies, diagnoses, treats and manages mental health and/or substance abuse problems in patients and family members.
• Knowledge of hospital, medical center and/or health system resources to access and provide for patient care needs.
• Maintains a working knowledge of community agencies and resources and serves as a liaison between them and the healthcare system.
• Collaborates for appropriate resource and financial management which may include but is not limited to-financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination.

SNP Social Worker on health plan’s medical management team

SNP Social Worker – Peak

SNP Social Worker assisting in coordination of benefits with MA and Medicaid. Integral member of the health plan’s medical management team attending to community resources and member health needs.

• Coordinate benefits with MA and Medicaid
• Connect members to community resources
• Participate in activities related to care management program
• Ensure compliance with CMS SNP Model of Care expectations
• Perform psychological, social and economic care management interventions
• Assist in the development of individualized care plans
• Document in the members’ case accurately and timely
• Collaborate with the interdisciplinary care team
• Maintain knowledge of community agencies and resources

SNP Social Worker collaborating with medical management team to improve health outcomes

SNP Social Worker integral to health plan’s medical management team. Collaborating on member care, ensuring compliance and connecting to resources while improving health statuses.

Social Worker jobs in West Virginia

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Social Worker, BSW

Master Social Worker – MSW

SNP Social Worker – Peak

SNP Social Worker – Peak