Job Description

The Social Worker in the Continuing Care Department is an integral member of a hospital patient’s care team, responsible for assessing and intervening to ensure the effective continuation of a patient’s care after discharge from the hospital. The social worker will be assigned to a unit or units, which may include medical, surgical, intensive care, OB/Maternity, pediatric, and/or Emergency Department, and will work closely with physicians, nurses, and other practitioners on the assigned unit. Social Worker is responsible for interviewing hospital patients and family members/caregivers; facilitating family meetings to identify needs and develop continuing care plan; assessing psychosocial needs; counseling patients and family members to promote effective coping and treatment plan compliance. Other duties include assessing knowledge deficits; educating patients and family members about community resources, rights and responsibilities, advance directives, end-of-life care issues, health insurance, and navigating the health care system. The Social Worker coordinates complex care plans involving a wide range of internal and external services including home health, social services, rehabilitation, and mental health providers; advocates for patients to receive needed resources and services. Functions as part of a multidisciplinary team. As opportunities arise, the Social Worker will participate in department and hospital initiatives related to process improvement and patient care. Education: Masters’ in Social Work; equivalent experience or certification considered. Licensures/Certifications: Licensed in Maryland as a LMSW or LCSW. Experience: 1-3 years prior social work experience in a hospital, nursing care facility or other health care setting preferably doing discharge planning work. Skills: Cultural competency and willingness to work with patients of many different racial, national, ethnic, and religious backgrounds as well as different age groups and socioeconomic statuses. Basic computer skills (electronic medical record training is provided). Interview skills including active listening, open-ended questioning, and empathy. Assessment skills to quickly develop thorough assessments and care plans. Skill in, or willingness to learn, counseling and motivational interviewing techniques. Willingness to engage with difficult or noncompliant patients or family members; willingness to discuss topics such as end of life care or substance abuse. Ability to self-direct and negotiate competing priorities. Ability to develop a wide-ranging working knowledge of services, referral processes and criteria, medical terms and needs, etc. (training is provided). Ability to work in a fast-paced environment; desire to engage with change processes and work closely with multi-disciplinary teams. Patient & Workplace Safety: Employee has knowledge and understanding of patient and workforce safety as it relates to job duties. Patient Population: Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.

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