In collaboration with the health care team, the social worker assists patients and families with personal and environmental difficulties with predisposed illness or interferes with obtaining maximum benefits from medical care. Services include providing patient and families with the psychosocial support needed to cope with disease and life limiting illness, advising family and caregivers, providing education and support, and making referrals for other services as needed or requested.
Provides psychosocial assessments of patients and families to identify emotional, social, and environmental strengths and problems related to their preventative health management, diagnosis, illness, treatment, and/or life situation.
Utilizes social work experience to plan and coordinate patient care.
Coordinates the transition plan with the care team and recommends further treatment for the patient to achieve optimal level of healthy lifestyle, behaviors, and functioning. Evaluates the plan at appropriate intervals and modifies the plan as necessary. Monitors, evaluates, and records client progress according to measurable goals described in treatment and care plan.
Monitors healthcare resource utilization such as ED, urgent care, admissions, or frequent office visits. Collaborates with team to address unnecessary utilization and plans for appropriate support to modify process behaviors.
Arranges and coordinates assistance/referrals for unmet patient/family needs, to include social service, financial, and insurance applications and follow up, medications, DME, and transportation to/from clinic appointments. Plan of care promotes compliance as well as considers appropriate utilization of resources. Advocates on behalf of the patient.
Participates in care transitions planning and post-discharge follow up to assess psychosocial and support needs and reinforces patient self-management expectations and goals.
Collaborates with other professionals to evaluate patients' medical or physical condition and to assess patient needs.
Collaborates with community agencies and resources to develop a comprehensive knowledge base of available resources for patients and families. Networks with community resources to build strong working relationships. Maintains an extensive knowledge of benefit plans, regulatory guidelines and resources and serves as a resource to maximize utilization and cost effectiveness.
Refers patient or family to community resources to provide access to services such as financial assistance, legal aid, or housing. Refer to DSS with suspected abuse or neglect of child or adult.
Meets documentation standards for quality, timeliness, and confidentiality of medical records in accordance with organizational and departmental defined policies and procedures. Maintains records and statistics in accordance with department and medical center policies.
Remains current with social work and health care developments and seek to increase further enhancement of job related knowledge. Identifies social problems and advocate for change.
Provides education and self-management strategies to patients and families around issues related to adaptation of the patient's health and addressing any contributing barriers to achieving goals.
Consistently deliver the best in customer service and patient care. As a team member, demonstrate respect, dignity, kindness and empathy in each encounter with patients, families, visitors and other employees.
Champion Carilion's mission, vision and values; comply with the policies and procedures, ethical standards and code of conduct set forth by the company.
Benefits, Pay and Well-being at Carilion Clinic
Carilion understands the importance of prioritizing your well-being to help you develop and thrive. That's why we offer a well-rounded benefits package, and many perks and well-being resources to help you live a happy, healthy life – at work and when you're away.
When you make your tomorrow with us, we'll enhance your potential to realize the best in yourself. Below are benefits available to you when you join Carilion:
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