The Social Worker provides program enrollment services at bedside which may include financial screening, resource identification/information and referrals. The Social Worker also develops and carries out a plan of care requested by the Hospital or Nurse Navigator, which will enhance the client’s capacity to function in his or her environment as well as to assist the family and client to adapt to illness. SW may conduct in-home assessments to ascertain client and caregiver needs, develop a plan of care with input from the interdisciplinary team and evaluate effectiveness of care provided. The goal is to provide information and guidance to the client and caregivers in hospital to improve client self-management skills and enhance client-healthcare provider communication. The primary role is to act as a program enrollment ambassador, client educator, and advocate and client empowerment facilitator.
The Social Worker is able to work independently as well as communicate effectively with clients, families, staff and the community.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Provide program enrollment services that meet program criteria
- Assist with Social Determinants of Health at client bedside
- Work Collaboratively with Case Management, Providers and Community Resources
- Demonstrates an ability to provide skilled social work services and assessments as requested by the Hospital or Nurse Navigator.
- Meets with interdisciplinary team to support client transitions
- Conducts in-home assessments with client and caregiver
- Creates a plan of care and documents as required
- Performs client-centered and solution- focused enrollment services
- Prioritizes client enrollments according to intensity, need, and required follow-up
- Provides information and guidance during hospital stay to assist client and caregivers for improved client self-management skills and enhanced client-healthcare provider communication
- Acts as a continuing resource for the client, caregivers and nurse navigator for a minimum of three months, with decreasing intensity
- Gives regular feedback to the interdisciplinary team; participates in departmental and organizational committees as applicable
- Maintains East Valley database and reports. Makes accurate and timely documentation
- Understands ACTIVATE enrollment goals and assists in growing ACTIVATE throughout the hospital and community sectors.
- Demonstrates an ability to accurately assess physical, social and emotional factors related to the client’s ability properly participate in ACTIVATE navigation services
- Employs a variety of resources or referrals to assist clients with illnesses, counseling, behavioral and educational needs prior to discharge.
- Helps the client to understand, accept and follow medical recommendations and other services provided that are planned to restore the client to optimum social and health adjustment within his or her capacity.
- Promotes continuity of care by making appropriate contact with prior sources of care and follows up with discharge planning.
- Maintains a current knowledge of community resources which will meet a variety of client needs and provides information and referrals to clients and other staff members when indicated.
- Provides a standardized approach to client screening to determine program and resource eligibility.
- May be available for consultation with interdisciplinary teams, hospitals, clinics or other community agencies as deemed appropriate.
- Documentation is accurate, complete and legible.
- Submits all clinical record documentation in a timely manner as designated by agency established procedure.
- Demonstrates appropriate judgment and adequate consultation in communicating with the interdisciplinary teams to assist in evaluation of the client.
- Develops and maintains effective communication with all health care team members, clients, and family members.
- Attends mandated in-services.
- Provides case consultation and management as requested.
- Participates in agency quality assurance activities and assists in clinical audits as requested.
- Supports program data collection, data entry and documentation needed from East Valley sector.
- Promotes ACTIVATE within the community and increases community awareness, resources or relationships in the East Valley
- Other duties as needed
KNOWLEDGE, SKILLS AND ABILITIES:
- Must be CPR certified & TB Test.
- Must have valid Arizona Driver’s license and reliable transportation.
- State Certification.
- Work well independently.
- Must be self-motivated and use good judgment to resolve client issues.
- Must demonstrate good organization skills and be detail oriented.
- Good assessment skills.
- Good communication skills.
- Familiar and competent with Microsoft Word software and general computer skills.
- Like challenges and working in the constantly changing environment of home health care.
- Must be a good “problem solver” who enjoys working in a diverse environment.
- Have a clear understanding of the Medicare and State guidelines, and be willing to work with people and learn new tasks with a willingness to see that the job is done correctly.
- Must not have any restrictions for physical work for which reasonable accommodation cannot be made.
- Assist with clerical tasks as needed.
- Prepare monthly statistics/reports for director.
WORK EXPERIENCE AND EDUCATION:
- BSW Degree in Social Work.
- Must have experience working with vulnerable populations and ensure that their basic needs are met.
- 1-3 years of experience
- LMSW LCSW
***Military Personnel Encouraged to Apply.***
FSL is an Equal Opportunity/Affirmative Action Employer, M/F/D/V. DFWP. FSL believes that diversity leads to strength.
FSL is a proud Wellness AtoZ Platinum employer! FSL is a Gold Award recipient of the Healthy Arizona Worksite Program (HAWP)