Social Worker- Outpatient BSW- Days

Description: The Social Worker - Outpatient BSW assists patients and their family members by obtaining services or initiating referrals in an effort to eliminate personal or environmental barriers which may interfere with maximum benefits of health care. This job supports the provider and interdisciplinary team in facilitating and coordinating patient care through the continuum. Typical Duties: Performs psychosocial assessments to identify individualized needs and develops a plan to address each need that takes into consideration the requests of the patient/family. Makes referrals to the appropriate resources within the JPS Health Network and within the community. Collaborates one-on-one, in huddles or team meetings with Providers, Nurse Case Managers and Patient Centered Medical Home (PCMH) staff focusing on identifying the needs of complex high risk patients. Provides brief supportive counseling to patients and families exhibiting complex family dynamics directly impacting patient care. Assists patients and families to cope with and manage life-changing diseases, death and dying, advanced directive education, disabilities, etc. Supports patients and providers with reviewing and completing various eligibility forms for social programs, funding sources, durable medical equipment, etc. Follows-ups with patients and families ensuring that services provided are helpful, appropriate, and adequate. Develops and sustains long term working relationships with patients and families. Aids with care coordination for patients with complex psychosocial needs including providing services in a variety of settings (i.e. PCMH, patient homes, hospitals and other health care locations). Educates patients and families regarding various care options (i.e. home care, nursing home, hospice, etc.) and ensures that the patient’s choices are incorporated into the care coordination plan. Documents each component of the case management process and related activities in the electronic medical record system according to departmental guidelines. Assists with cost containment, short-term intervention, ambulatory and community-based care, and decentralization of services. Works as a member of the interdisciplinary team as the patient advocate. Complies with National Association of Social Workers (NASW) Code of Ethics and maintains legal and regulatory accountability. Performs other job related duties as assigned. ?