Medical Social Worker - BSW - Care Coordination

How You’ll Help Transform Healthcare :

Position is primarily remote, but may require occasional travel for meetings, patient interactions. This is a social work position that will involve working with patients by phone to help address health related social needs.

Is an integral part of the care team, contributing professional expertise to support the holistic health of the patient and support for family and / or other caregivers.

In collaboration with the health care team the medical social worker assists patients and families with personal and environmental difficulties which predispose illness or interfere with obtaining maximum benefits from medical care.

Provide patient and families with the psychosocial support needed to cope with disease and life limiting illness. Services include advising family and caregivers, providing education and support, and making referrals for other services as needed or requested.

Provide 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.

Utilize assessment and social work experience to plan and coordinate patient care.

Formulate, develop, and implement a comprehensive treatment plan utilizing appropriate social work interventions. Coordinate the plan with the care team and make recommendations for further treatment for the patient to achieve his / her optimal level of healthy lifestyle, behaviors and functioning.

Evaluate the process at appropriate intervals and modify or change the plan as necessary. Monitors utilization of healthcare resources such as ED, urgent care, admissions or frequent office visits.

Collaborates with team to address unnecessary utilization and plan for appropriate support to modify process behaviors. Monitor, evaluate, and record client progress according to measurable goals described in treatment and care plan.

Arranges, secures, and coordinates assistance with 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.

Advocates for patients to assist in crises situations.

• Participates in care transitions post hospital and / or ED 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 comprehensive knowledge base of available resources for patients and families.
• Refer patient or family to community resources to provide access to services such as financial assistance, legal aid, or housing.
• Participates in care team pre- and post visit case reviews and related meetings. Collaborates with the health care team and / or care coordinator verbally or via chart entries related to the patient’s progress toward reaching expected outcomes or about barriers to the plan.
• Meets documentation standards for quality, timeliness and confidentiality of medical records in accordance with organizational and departmental defined policies and procedures.

What We Require :

Education : Bachelor's Degree in social work required

Experience : Social work experience in health care setting preferred. Team work is a must.

Other : Must successfully complete orientation and competency validation for position. Demonstrates critical thinking and creative problem solving skills to move patients effectively and efficiently through the continuum of care.

Ability and willingness to work as an integral member of a multi skilled team. Inspiring Better Health at Carilion Clinic Every day at Carilion Clinic, our employees come together to inspire better health in our patients, their families and our communities.

Explore how you can be a part of this diverse, innovative and interdisciplinary patient-centered team, and find out how you can make a difference in the lives of others.

As an employee, you can take advantage of our competitive pay, various scheduling options, continuing education opportunities and excellent benefits.

Based in Roanoke, Va., Carilion Clinic includes multi-specialty physician practices, seven not-for-profit hospitals and the Virginia Tech Carilion School of Medicine and Research Institute in partnership with Virginia Tech.

Service Excellence and Quality are hallmarks of Carilion Clinic. As a team member, you will be expected to consistently deliver the best in care and customer service.

As an employee, you will demonstrate respect, dignity, kindness and empathy in each encounter with our patients, families, visitors and with each other.

Equal Opportunity Employer Minorities / Females / Protected Veterans / Individuals with Disabilities / Sexual Orientation / Gender Identity.

Carilion Clinic is a drug-free workplace.

About Carilion

This is Carilion Clinic ...

An organization where innovation happens, collaboration is expected and ideas are valued. A not-for-profit, mission-driven health system built on progress and partnerships.

A courageous team that is always learning, never discouraged and forever curious.

Headquartered in Roanoke, Va., you will find a robust system of award winning hospitals, Level 1 and 3 trauma centers, Level 3 NICU, Institute of Orthopedics and Neurosciences, multi-specialty physician practices, and The Virginia Tech Carilion School of Medicine and Research Institute.

Carilion is where you can make your own path, make new discoveries and, most importantly, make a difference. Here, in a place where the air is clean, people are kind and life is good.

Make your tomorrow with us.

Requisition Number : 148750

Employment Status : Full time

Location : CASB - Carilion Administrative Services Building

Shift : Day

Shift Details : Monday - Friday, 8am - 5pm

Recruiter : DANA E JOHNSON

Recruiter Email : [email protected]

For more information, contact the HR Service Center at 1-800-599-2537.

Equal Opportunity Employer

Minorities / Females / Protected Veterans / Individuals with Disabilities / Sexual Orientation / Gender Identity

Carilion Clinic is a drug-free workplace.