Medical Social Worker

GARDNER

Medical Social Worker

Social Services, 40-Hours, Days, Monday - Friday, Every other weekend

Essential Functions

Care Transitions & Coordination: Reports directly to the Manager of Care Transitions and Indirectly reports to Unit Manager and Practice Leader.
Keeps department leaders abreast of any issues, trends identified and/or needs weekly and/or more frequently if needed.
Demonstrates professionalism and teamwork. Works collaboratively with unit team and responds timely, efficiently and respectfully. Covers for co-workers during planned and un-planned absences and as requested by leadership.
Provides service to community at large through the provision of service to Walk-In and telephone inquires as assigned by leader and/or designee as needed.
Conducts comprehensive psychosocial assessments for patients and families. Identifies social, emotional, financial, and environmental barriers to care. Assesses mental health concerns, coping ability and support systems.
Completes the Assessment fully, clearly, concisely, and within 24-48 working hours of being assigned the case.
Completes documentation using the documentation standards noted by department policies and procedures, as well as, state and federal regulations.
Completes clear and concise documentation noting patient and family participation, multidisciplinary involvement, and other planning information as required by the department, as well as, state and federal regulation agencies.
Discharge Planning: Communication: builds rapport and responds to needs of physician, healthcare team members, 3rd party payers, referral sources and vendors to enhance internal and external customer service satisfaction.
Conducts High Risk Screening on all patients on assigned units for potential needs as per policy. Completes HRSN Screen within 24 working hours of case assignment.
Effectively supports the discharge planning process by ensuring services and placements are appropriate within the continuum of care. Completes required documentation accurately and in a timely manner, maintaining compliance with regulatory standards.
Demonstrates strong performance in educating patients on their rights, consistently providing accurate, timely, and comprehensive information. Ensures patients understand applicable processes and resources, supporting informed decision-making and maintaining compliance with regulatory and organizational standards.
Provides short-term counseling to patients and families coping with illness, trauma, grief or adjustment challenges. Supports patients dealing with chronic illness, terminal diagnoses or major life changes.
Effectively provides patients and families with clear, relevant education regarding the care plan, tailored to individual needs. Collaborates closely with the multidisciplinary team to ensure coordinated, patient-centered care and support continuity across settings.
Responds to psychosocial crises, including: Domestic violence, abuse or neglect concerns, suicidal ideation and family conflict.
Advocates for patients' rights, dignity and access to appropriate care. Addresses barriers related to social determinants of health.
Conducts post discharge follow up on High Risk patients in an attempt to reduce re-hospitalization.

Job Requirements

Minimum Education

Associates Degree required, Bachelor's Degree preferred in SW or related field
Minimum Work Experience

Minimum one to three years experience in a hospital setting, Skilled Nursing Facility, or community social/health agency.
Minimum Licenses and Certifications

MA State licensure required LCSW, LSW, or LSWA.