Licensed Social Worker

6 days ago

Danville, California, United States Geisinger Health System Full time
Job Summary:

The Social Worker serves as a liaison between hospital, Geisinger at home, Care Coordination & Integration, and community agencies for the exchange of clinical and referral information.

Interacting with Geisinger Health Plan lines of business and Keystone Accountable Care Organization members, patient support systems, interdisciplinary inpatient and outpatient health care professionals, and community and state agencies.

Identifies high risk patients from a psychosocial/financial perspective, assesses the psychological needs of patients and support systems, providing information, support, counseling, care management, and referrals to appropriate resources.

Collaborates with the interdisciplinary health care professionals to ensure patient needs are met and care delivery is coordinated across the continuum to optimize discharge planning home in a timely manner.

Resolves psychosocial patient care issues and develops and implements a complex patient transition/discharge plan.

Collaborates with onsite Geisinger at Home Registered Nurse Case Manager to implement home-based model of health care in discharging planning.

Job Duties:

Collaborates with inpatient and outpatient Case Management healthcare professionals in development of personalized, timely, and safe discharges home.

Identify and resolve barriers to Geisinger Health Plan (GHP) lines of business and Keystone Accountable Care Organization (KACO) members returning home from hospitalization.

Participates in the screening and identify appropriate members for Population Health Management.

Identifies and provides support in addressing social determinates of health.

Participates in daily interdisciplinary team meetings inpatient at Geisinger Facilities and collaborate with inpatient team in development of a plan of care for Population Health Management established/potential patients.

Monitoring of GHP & KACO members patients while admitted to Geisinger Facilities.

Screening, engaging, and scheduling of home visits at bedside to optimize transition of care process.

Incorporates Geisinger at Home Registered Nurse Case Manager to implement home-based model of health care in discharging planning.

Engaging with members at bedside.

Communicating with patient family/caregivers at bedside or phone call in efforts to optimize timely discharge planning.

Complete/continue advanced care planning discussions at bedside.

Initiates and monitors completeness, accuracy, and timeliness of all documentation.

Provides documentation of initial assessments and reviewing of all referrals for accuracy and content prior to discharge.

Reports potential risk or quality management.

Escalates issues to resource as necessary to resolve barriers through appropriate administrative and medical channels.

Collaboration with behavior health managed care organization regarding GHP Family Plan Holders.

Collaborates with outpatient interdisciplinary patient care professionals to update on discharge planning.

Work is typically performed in a clinical environment.

Accountable for satisfying all job specific obligations and complying with all organization policies and procedures.

The specific statements in this profile are not intended to be all-inclusive.

They represent typical elements considered necessary to successfully perform the job.

Position Details:

Hours:
Monday through Friday; 8-hour shifts; 8:00a-4:30p

Education:
Master's Degree is Social Work is required; Licensed Social Worker is required

Experience:
2 years' experience with Advanced Care Planning and Family Decision Making is preferred

Our Benefits:
We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally.

We believe in creating a diverse and inclusive environment where all employees can be their authentic selves.

We know that a diverse workforce with unique experiences and backgrounds makes our team stronger.

We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.

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