The role of the Social Worker, General is to assist individuals, families, and internal teams who are impacted by Social Determinants of Health (SDOH) needs. The objective of the Social Worker is to assist the individual and/or family to access services and provide available resources within Steward Health Care Network (SHCN) and the community.
- Provides telephonic care coordination services to high risk patients that are impacted by Social Determinants of Health such as: food insecurity, financial resources, legal assistance, transportation, applying for disability, accessing services, application assistance, etc.
- Provides advocacy, patient education and support in accessing community-based and hospital-based programs.
- Utilizes resources of public and private agencies and community organizations to meet the needs of patients and families.
- Assists patients with organizing their records, making follow-up appointments, and filling their prescriptions.
- Helps patients fill out applications, for example for Medical Assistance and SNAP (Supplemental Nutrition Assistance Program)
- Makes referrals to case managers, as appropriate, and/or refers patient’s family to community support services and resources.
- Schedules and completes initial assessment, develops a patient-centric plan of care and schedules follow-up within specified timeframes
- Initiates telephonic or face to face contact with high risk patients of all ages to conduct a Care Needs Screening
- Evaluate Care Needs Screening responses and make appropriate referrals to internal care management programs or to external resources.
- Records and monitors the participants’ progress toward goals within specific timeframes
- Collaborate with youth and family service agencies at the local, county and state level including but not limited to schools, special education services, DCFS, family court systems.
- Works collaboratively with the members PCP and/or other key providers in planning and directing each patient’s treatment program
- Clearly documents all activities in the patient record
- Provides concise and thorough documentation through psycho/social assessment and progress notes, including changes in medical psycho/social functioning, progression and attainment of goals, referrals to internal and external agencies, and contact/involvement with patient’s family.
- Demonstrates cultural sensitivity and respect for the patient
- Bachelor’s Degree in Social Work, Psychology, Counseling, Rehabilitation or other related field, required
- Master’s degree preferred
- BLS Certified (CPR/First Aid)
Years of Experience:
- Minimum of 2 years working within health care environment