JOB SUMMARY: The Social Worker will evaluate the psychosocial needs of patients and family support systems and will coordinate appropriate discharge plans for identified patient populations. The Social Worker acts as a liaison between the facility and resources external to the organization. He/she will facilitate implementing timely discharge plans and facilitate follow-up to anticipated post-acute interventions identified in the plan of care. The Social Worker will provide crisis intervention and support. The Social Worker will assist the Resource Manager in facilitating patient movement across the continuum of care and will identify and track barriers to patient throughput.
Performs a comprehensive assessment of psychosocial needs of assigned patients
Assesses patients discharge needs and facilitates the provision of services necessary to meet identified needs
Evaluates suspected abuse and neglect referrals and makes official reports
Develops an individual plan of care for recurring patients to include education related to accessing healthcare services at the appropriate level of care
Provides education to the under-resources patient/family of potential and available resources
In collaboration with the interdisciplinary team, develops, implements, evaluates, revises as needed, a discharge plan to include identifies psychosocial an discharge needs
Documents professional recommendations, care coordination interventions, and case management activities to effectively communicate to all members of the health care team
Participates with the interdisciplinary team to ensure psychosocial and discharge needs are addressed
Acts as a liaison through effective and professional communications between and with physicians, patient/family, hospital staff, and outside agencies
Demonstrates knowledge of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives
Makes appropriate referrals, after collaboration with the Case Manager, to third party payer disease and case management programs for recurring patients and patients with chronic disease states
Facilitates patient throughput with an ongoing focus on quality outcomes and an efficient transition between levels of care
Tracks and trends barriers to care, makes recommendations and develops action plans to improve processes and systems
Provides psychosocial support to patients and families through crises intervention
Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered
Acts as an advocate for identified needs and makes appropriate referrals
Acts as a liaison between the facility and community resources to enhance community outreach coordination
Tracks and trends variances barriers related to access to care
Adheres to established policy and procedure and standard of care
RISK MANAGEMENT (NOVICE): - Possesses sufficient fundamental proficiency to successfully demonstrate risk management of moderate difficulty. Capable of conducting risk analysis as part of a task to address problems including determining risk factors, probability, impact, early detection and prevention. Able to prepare simple contingency plans and alternatives.
PATIENT ASSESSMENT - (NOVICE): - Possesses sufficient fundamental proficiency to successfully demonstrate patient assessments in practical applications of moderate difficulty.
PATIENT EVALUATION (NOVICE): - Possesses sufficient fundamental proficiency to successfully demonstrate the ability to conduct a patient evaluation in practical applications of moderate difficulty. Capable of effectively assessing the relative merits of alternative products or services.
CRISIS INTERVENTION (NOVICE): - Possesses sufficient fundamental proficiency to successfully demonstrate crisis intervention in practical applications of moderate difficulty.
CLINICAL COUNSELING (NOVICE): - Possesses sufficient fundamental proficiency to successfully demonstrate clinical counseling in practical applications of moderate difficulty.
Internal Number: 2002160
About Vanderbilt Health
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period.Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As th...e largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.