Position Objective:

Provides counseling, crisis intervention, and transition planning services to AAMC patients of all ages and their families. Performs psychosocial assessments, plans for and implements identified services for patients.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

1. In accordance with established department and professional guidelines, provides comprehensive psychosocial assessments for patients identified by Care Coordinator, and/or interdisciplinary team.
2. In counseling role, creates a therapeutic framework for effective problem solving with patient and family. Responds to patient/family needs related to adjustment to illness, disability, critical care issues, acceptance of discharge recommendations, need for long-term care placement, end of life, grief, trauma, abuse and neglect, substance abuse, and mental health issues.
3. In collaboration with Care Coordinator, provides transition of care strategies in complex situations such as: substance abuse, psychiatric, or dual diagnosis placement/services, ventilator dependent patients, inpatient dialysis services, patients with no insurance needing skilled nursing facility placement, patients requiring guardianship, long term/custodial placement.
4. Identifies community services and resources available to patients and families and facilitates linkage with those services.
5. Collaborates with the interdisciplinary team and communicates to him/her the progress and status of referred patients. Makes recommendations and revises plan based on continued evaluation and collaboration. Communicates proactively with members of care management and the interdisciplinary team as appropriate and indicated.
6. Evaluates patient/family progress toward established goals. Participates in Care Conferences and Complex Care rounds as indicated to address patient/family issues/barriers and to help facilitate safe transitions of care.
7. Integrates medical record and nursing information in assessment and interventions.
8. Ensures timely, appropriate, and accurate evaluation and reporting of suspected child/elder abuse and or neglect. Assesses for domestic violence issues and involves domestic violence program coordinator as indicated and appropriate.
9. Documents interventions in patient's medical record following department standards.
10. Participates in process improvement activities in the care management department. Identifies opportunities for improvement and recommends.

Educational/Experience Requirements:

• Master of Social Work degree.
• Six months experience in healthcare delivery system required, preferably acute care.

RequiredLicense/Certifications:

• Current license as a Licensed Master Social Worker (LMSW).

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.