Faith Regional Health Services Job - 45879004 | CareerArc
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Company: Faith Regional Health Services
Location: Norfolk, NE
Career Level: Associate
Industries: Healthcare, Pharmaceutical, Biotech


Work Status Details: Full Time | 80.00 Hours Every Two Weeks
Exempt from Overtime: Non-Exempt
Shift Details: Rotating Weekends and Holidays
Department: Care Management | Reports To: RN Manager-Care Management

The mission of Faith Regional Health Services is to serve Christ by providing all people with exemplary medical services in an environment of love and care.


The social services specialist is responsible for working in a team structure with the RN Case Manager to effect overall care coordination with the emphasis on psychosocial assessment and intervention, complex discharge planning, knowledge of community resources, appropriate documentation in the medical record and networking and collaborating with other hospital disciplines and community agencies. The social services specialist assists the patient, family/guardian and all members of the healthcare team in the discharge planning process. Social services specialist is accountable for intervening with patients and families, by applying critical thinking skills to monitor psychosocial status and issues that impact the clinical progression and transition/discharge plan for patients including, coping and decision making. Demonstrates positive communication and interpersonal skills with patients, families and coworkers and participates in patient and family conferences as needed. The social service specialist must demonstrate the knowledge and skills necessary to provide age-appropriate patient care and is accountable to the policies and procedures of the organization. The Social Services in the Care Management Department is expected to adhere to the hospital and social work codes of ethics.

The listing of job duties contained in this job description is not all inclusive. Duties may be added or subtracted at any time due to the needs of the organization.


Essential Job Duties and Responsibilities:

1. Demonstrates ability to appropriately modify approach and procedures to meet needs of age/diversity of population served for the following age groups:

☒ Neonate (birth – 28 days)

☒ Infant (29 days – less than 1 year)

☒ Pediatric/Child (1 year – 12 years)

☒ Adolescent (12 years – 18 years)

☒ Adult (18 years – 65 years)

☒ Geriatric (over 65 years)

    • Incorporates cultural considerations in the provisions of care.
    • Knowledge of growth and developmental stages.
    • Considers life changes/effects on health beliefs and behaviors.
    • Provides necessary safety measures.
    • Provides information and involves family/caregiver in decision making.

2. Performs all responsibilities/duties required by the Care Management Department as defined in the scope of practice, to assure that the unique nature of the patient is addressed. This includes, but is not limited to, the age of the patient served.

    • Participates and implements discharge planning activities for complex patients in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers.
    • Evaluates all assigned patients and referrals and identifies discharge planning needs in accordance with established criteria.
    • Collaborates with the Nurse Case Managers on the initiation of the discharge plan within 48 hours of admission.
    • Communicates with the patient/family and healthcare team to assess and identify individual discharge needs and desires, including those specific to the age of the patient being served (neonate, child, adult, and geriatric).
    • Assists the patient/family and healthcare team in implementing the discharge plan.
    • Assists the patient/family in investigating eligibility and applying for Medicaid or SSI by referring to the financial counselor as appropriate
    • Utilizes community resources and refers the patient/family to appropriate agencies and services when necessary.
    • Communicates with extended care facilities to assure bed availability and arranges placement.
    • Arranges transportation for emergent and non-emergent transfers via ambulance, air ambulance, non-emergent transport, private vehicle, etc.
    • Arrange home health care for complex patients including necessary equipment and personnel prior to discharge.
    • Documents patient interviews, evaluations, recommendations and summarizes in the medical record.
    • Revises documentation, as circumstances warrant, keeping patient information current and up to date.
    • Collaborates and works in partnership with the interdisciplinary treatment team in the transition/discharge planning for patients; regularly participates in team meetings and/or updates team on a regular basis.
    • Communicated information and judgements, based on interaction with patient/family, and keeps appropriate people aware of pertinent changes or problems in a patient's condition, as observed.
    • Demonstrates ability to prioritize workload in accordance with patient needs and in accordance with departmental goals and objectives.
    • Research resources available to meet the social, economic, and emotional needs of the patient.
    • Observes all established policies and procedures throughout the daily work routine.
    • Assesses the patient's and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.
    • Maintains a working knowledge of financial reimbursement methodology for all payers to identify any financial risk/ need for acute care admission as well as post-discharge placement.
    • Maintains knowledge of community resources and keeps a referral directory with updated information of available services and contact information.
    • Applies advanced problem-solving techniques in planning, assessing, implementing and evaluation of patient discharge needs.
    • Understands the Care Management/Social Services philosophy and principles of interdisciplinary team management and collaborative practice.
    • Intervenes when variances occur in the patient's individualized discharge plan.
    • Assists with discharge planning needs and inappropriate admission prevention in the Emergency Department (ED) and Clinical Decision Unity (CDU).
    • Identifies and documents avoidable days/delays daily.
    • Notifies financial services of unfunded patients.
    • Ability to communicate with patients and their families regarding Important Message from Medicare (IMM), Appeal rights, Hospital Issuance of Notice of Non-coverage (HINN), Advance Beneficiary Notice (ABN), processes and deliver notifications.
    • Provides social services to patients in outpatient areas of FRHS as well as Home Health and Hospice patients under the care of FRHS Home Healthcare.
    • Demonstrates flexibility as patient needs and census changes.


Hospice Social Service Specialist Essential Functions

    • Assess patient/family social and emotional factors in order to estimate their potential to cope with terminal illness and death
    • Provide psychosocial counseling and support to the patient/family experiencing social, and economic conflict
    • Assist patient/family and staff in utilizing community resources
    • Assess patient/family financial and insurance status and assist with appropriate resources as indicated
    • Responsible for maintenance of electronic medical records, assuring accuracy, completeness and compliance with regulations, certification standards, legal and ethical standards
    • Identify and address comfort care needs in collaboration with other members of the Home Health Care team
    • Coordinate patient and family services
    • Provide psychosocial education to patients, family, and caregivers about coping skills, hospice and palliative care
    • Facilitating advance care planning and lifespan planning
    • Mediating conflicts with families, between clients and the care team and between service organizations
    • Maintain the dignity of the dying patient
    • Support the patients and family's unique spiritual and cultural beliefs
    • Assist patient/family with end-of-life plans such as funeral arrangements or establishing an advanced director
    • Attends the weekly interdisciplinary team meetings
    • Assess family regarding bereavement risk, and offer/provide emotional support to survivors through mailings, calls, and coffee support meetings to bereavement families for a minimum of 12 months' post death
    • Refer survivors on to professional assistance if note complicated/high risk grief.   

Hours will be dependent on patient census and workload. Ability and willingness to work a flexible schedule, to include after-hours and weekends as necessary.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Other information:

Job Requirements:


Bachelor's Degree required.


Social Work or related field required.

Previous Experience Requirements:


Previous healthcare experience preferred.

Two years of previous experience in field preferred.

Skills/Knowledge Requirements:


Ability to read, write, speak, and understand the English language required.

Other Certifications/Requirements:

Current, valid driver's license issued in the state of legal residence (if assigned to Home Health/Hospice department) required.

 Will operate FRHS owned vehicles (if assigned to Home Health/Hospice department).


Faith Regional Health Services is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.

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