DescriptionSHIFT: No Weekends
Social Worker Inpatient Rehab Medical City Lewisville
Position Summary: Under general supervision of the Program Director of Inpatient Rehabilitation, the Inpatient Rehabilitation Unit Social Worker is responsible for leading care coordination and assessment of discharge plan for patients requiring inpatient rehabilitation. Concurrently screens patients to identify and facilitate discharge planning needs with emphasis on culture, financial considerations, and family dynamics. Coordinates discharge plans with individual patients, families, physicians and other members of the health team. Functions in a case management role for the Inpatient Rehab Unit, coordinating the care and service of the rehab population across the continuum, promote effective utilization, monitor health care resources, and assume a leadership role with the interdisciplinary team to achieve optimal outcomes using the tools of case management.
Job Duties and Responsibilities:
- The Social Worker will assist in the facilitation of care across the continuum for patient care needs in the Inpatient Rehab Unit (IRU)
- Deal tactfully with medical staff members, hospital personnel, state, local, and federal personnel as well as other members of the healthcare team
- Knowledgeable of local, state and federal regulation pertaining to federally funded programs as they relate to utilization review, discharge planning and financial reimbursement.
- Conducts initial evaluation and assessment of each patient including as applicable: living situation, mental and medical status, family/significant other's involvement, and financial status.
- Participates in team conferences, arrange, facilitate, and document family conference
- Maintain insurance approval of patients in the Rehab unit. Manages the Utilization Review process and maintaining continued stay requirements for all patients.
- Discharge planning with the family and conditioning of any discharge needs, and counseling with patients and/or families as necessary within the scope of Social Work license.
- Provides patient and family education regarding rehabilitation program and goals as well as information regarding patient's diagnosis in order to facilitate appropriate social and health adjustment.
- Coordinates effective discharge plan arranging for home health/outpatient follow up treatments and networks with appropriate community agencies to facilitate transition to the community
- Documents appropriate pertinent information and progress in the medical record
- Communicates all pertinent information relating to patient and family system to unit staff
- Conveys information in an effective and timely manner regarding social, psychological, emotional and family problems that may impact the rehab effort.
- Coordinates efforts with other team members to help identify and alleviate potential problems that might impeded patient's progress
- Confers with team members in formal conferences weekly and informally as needed
- Acts as a liaison between patient, family, and interdisciplinary team members to facilitate communication and support treatment plan and discharge planning
- Maintains regular contact with family members to provide them with updates on patient progress and other pertinent information
- Provides direct counselling services to meet the immediate needs of patients within scope of practice to assist them with coping with the stressors related to illness or hospitalization and provide recommendations to support the emotional and social needs of patients.
- Assists team with patient and family support groups.
- Communicates all pertinent information relating to discharge planning to ensure appropriate home care plan.
- Provides information regarding type and schedule of services to be provided, agency name and phone number, and team recommendations for home care to patient and family prior to discharge.
- Evaluation of psychosocial needs based on physical, emotional, social barriers and physical limitations.
- Crisis intervention and end of life support
- Engages patient/family in goals, treatments, and discharge planning process.
- Ability to collaborate with case managers, physicians, staff, families and community referral bases to enhance optimal patient outcomes.
- Ability to coordinate service delivery to ensure continuity of care and services
- Ability to recognize the age specific, cultural, and religious needs and behaviors of the IRU patients
- Ability to prioritize independently and respond timely to multiple simultaneous requests
- Ability to problem solve, and seek assistance from appropriate community agencies
- Working knowledge of community, regional and governmental resources
- Understand Medicare and Medicaid regulations and payer guidelines related to discharge planning
- Possess the ability to deal tactfully with medical staff members, hospital personnel, state, local and federal personnel as well as other members of the health care team.
- Possess the ability to prioritize responsibilities and handle multiple projects simultaneously.
- Participates in hospital or departmental performance improvement activities, and seeks opportunities to improve department and inter-department processes.
- Serves as a resource to department staff, students, volunteers and other departments, and contributes to the teamwork essential to ensuring quality patient care.
- Takes appropriate measures to ensure safety of staff and patients.
- Reviews patients comprehensive health care assessment and history on admission, or as assigned to patient care team.
- Analyzes assessment data and formulates or modifies care plan in ongoing manner
- Utilizes interdisciplinary treatment plans for patients to facilitate achievement of expected outcomes in collaboration with interdisciplinary team.
- Monitors patient progress and conducts periodic reassessments of change in health status based on established procedures, protocols, and standards.
- Evaluates patterns of variances from standardized care plans and implements strategies to resolve them for individual and case types.
- Other duties as assigned
- Current Texas licensure/certification as LMSW, LCSW
- Master's Degree Social Work required
- Clinical experience in the management of the Inpatient Rehabilitation patient.
- 1-3 years previous Social Work experience within an acute medical or rehab healthcare setting preferred
- Well established leadership, problem solving, organization, and interpersonal skills
- Effective verbal and written communication skills.
- Computer and keyboarding skills. (25 wpm minimum)
- Ability to work with others to ensure quality patient care.
- Continuous focus on excellence in work environment.
- Must be highly analytical, logical and organized in approaching tasks.
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