Social Worker II

The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge, and prevent avoidable readmissions. This position integrates national standards for case management scope of services including: Transition Management promoting appropriate length of stay, readmission prevention, and patient satisfaction; Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care. Compliance with state and federal regulatory requirements, TJC accreditation standards, and Tenet policy; Education provided to physicians, patients, families, and caregivers; and Leads a population of patients by service line and/or leads the team by being a resource to Tenet performance standards.

• Conduct Comprehensive Psychosocial Assessments and Transition Planning - Perform complex psychosocial assessments, reassessments, and interventions to support patient transition and discharge planning.
• Coordinate and Manage Patient Care Transitions - Lead care coordination efforts, develop transition plans, and oversee implementation to ensure safe and effective post-acute care.
• Facilitate Multidisciplinary Collaboration - Lead and facilitate patient care conferences, collaborate with physicians and ancillary departments, and make appropriate referrals to support patient outcomes.
• Educate and Support Patients and Families - Communicate care plans to patients and families, ensure patient education is completed, and connect patients with appropriate community resources and services.
• Maintain Accurate Documentation and Quality Standards - Complete timely and concise case management documentation, maintain accurate patient information, participate in quality improvement initiatives, and support staff development through precepting and mentoring.
• Performs other duties as assigned/required.

• Required:
  • Education: Master of Social Work
  • Licensure/Certification:
    • MSW. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy.
    • Active license for state(s) covered.

• Preferred:
  • Experience: 2 years of acute hospital experience.
  • Licensure/Certification: Accredited Case Manager (ACM)