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Social Work Specialist

2 months ago

Denver, United States AdventHealth Full time

All the benefits and perks you need for you and your family: 

  • Benefits from Day One
  • Paid Days Off from Day One
  • Student Loan Repayment Program
  • Career Development
  • Whole Person Wellbeing Resources
  • Mental Health Resources and Support

Our promise to you:   

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind, and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.  

Schedule:  Monday through Friday either 8am - 5pm or 7:30am - 4pm, rotation of weekends needed then will be off during a week date. 

Shift:  Full Time

Location: 9395 Crown Crest Blvd, Parker Colorado 80138

The community you’ll be caring for:

The Social Work Specialist intervenes with patients who have complex psychosocial needs, require assistance with 
eligibility determination for social programs and funding sources and qualify for community assistance from a variety of 
special funds and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer 
crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a 
discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk 
populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other 
members of the care team).
The Social Work Specialist, in collaboration with the patient/family, care manager nurses, nurses, physicians and the 
interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work 
Specialist ensures efficient and cost-effective care through appropriate resources monitoring, and clinical care escalations.
The Social Work Specialist is under the general supervision of the Care Management Supervisor or Manager and is 
responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the 
implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Specialist is 
responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient 
satisfaction, patient safety, readmission prevention and length of stay management. 

The role you’ll contribute: 

●Psychosocial Assessment and Interventions

Assesses 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
oIntervenes with patients and families regarding emotional, social, and financial consequences of illness and/or 
disability; accesses and mobilizes family/community resources to meet identified needs
oServes as a resource to provide information and intervention related to treatment decisions and end-of-life issues
oProvides grief counseling and crisis intervention skills
oAdvocates for patient and family empowerment and independence to make autonomous health care decisions and 
access needed services within the healthcare system
oProvides de-escalation services for patients as appropriate
oProvide Motivational Interview techniques for patients with substance use and addictive disorders.
oProvides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention. Provides 
education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis.
oWorks in collaboration with hospital and community agencies to obtain needed services and resources for 
patients/families/caregivers.
●Receives referrals for psychosocial complex problems from the health care team.
●Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child 
protection and sexual assault, as appropriate
●Provides consult services for patients who may possibly lack decision making capacity. Follows the guardianship 
(temporary/ permanent) policies sand procedures and coordinates with Care Management leadership throughout the 
process
●Provides consult services for foster care and adoptions.
●Assists the health care team in the patient assessments and placements for mental health services.
●Facilitates full team discussion including patient and family when ethical dilemmas arise
●Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission
and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the 
patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation. 
●Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, 
Therapy notes, ED notes, test results and progress notes.
●Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and 
communicates these goals and preferences to the multidisciplinary team. 
●Incorporate clinical, social and financial factors into the transition of care plan. 
●Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care. 
●Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to 
meet the individual needs of each patient
●Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to 
transition of care plan achievement.
●Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate 
and facilitate high quality patient progression of care and transitions plans. 
●Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's 
readmission risk scores and coordinating readmission mitigation interventions.
●Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making 
needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
●Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to 
evolving patient care needs and ensure timely care coordination.
●Escalates issues barriers to appropriate level of Care Management leadership

●Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
●Facilitates patient care conferences with multidisciplinary team as needed.