Interacts with patients, family members, healthcare professionals, and community and state agencies. The Social Worker serves as a liaison between the hospital and community agencies or facilities for the exchange of clinical and referral information. Identifies high risk patients from a psychosocial/financial perspective, assesses the psychological needs of patients and families and provides information, support, counseling, care management, and referrals to appropriate resources. Works collaboratively with the interdisciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum. Resolves psychosocial patient care issues and develops and implements a complex patient transition/discharge plan.
Participates in the screening of participants and evaluates psychosocial surveys to ensure appropriate and successful group participation.
Provides support in developing the skills necessary for integrating lifestyle changes into daily life.
Participates in the interdisciplinary team development of a plan of care for each participant.
Participates in the monitoring, documentation, and communication of the participant's response to the interdisciplinary team plan of care.
Monitors group support adherence for all participants and provides additional explanation of guidelines on an individual basis as needed.
Assesses, plans and initiates patient plan of care.
Facilitates and coordinates details of placement and actual discharge to appropriate agencies.
Initiates and monitors completeness, accuracy and timeliness of all documentation.
Provides documentation of initial assessments and reviewing of all referrals for accuracy and content prior to discharge.
Reports potential risk or quality management.
Escalates issues to resource as necessary to resolve barriers through appropriate administrative and medical channels.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Master's Degree-Social Work (Required)
Minimum of 2 years-Related work experience (Preferred)
Certification(s) and License(s)
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 1...3 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.