The Social Worker, MSW position is responsible for the development, planning, implementation, and evaluation of all social service related interventions for the Case Management Department. Specifically, this position will be responsible for the identification of patients who have psycho/social needs an inpatient and outpatient setting. The social worker is responsible for developing patient care goals and treatment plans as agreed upon by the patient's primary care provider. The Ambulatory Case Manager/Social Worker is also available to physicians and nurse case managers as a consultant for those patients with complex psychosocial needs.
ESSENTIAL JOB DUTIES:
* Evaluate and implement with the assistance of the Manager of Social Work, a high touch ambulatory case management intervention for patients with psycho/social issues. With particular focus on seniors, catastrophic and chronic patients.
* Development: Depression Screening tools for selected populations; IS reports for outcome measurement
* Implementation: triage patients with the case management team; assist in coordination of patient care delivery, including DPA; document pertinent information in the case management system and communicate to team.
* Evaluation: evaluate caseload daily and assess achievement of long and short term goals; modify goals with providers and case management based upon patient outcomes; compile and present statistics and reports relating to patient outcomes; document findings in the patients chart or case management system
* Communication: provide follow up and outcome communication to the referral source, IE, PCP, family member, case manager, home health personnel, community social worker, Health Plan, etc.
* Act as social services liaison for the department and physician offices, particularly in the areas of:
* Complex discharge planning
* Referral to agencies which provide supportive services to fragile patients
* Assist in arrangement of community resources (i.e. meals on wheels, transportation services, adult day care, and info-line)
* Assist in long term planning for patients transitioning to an institutionalized setting
* Provide alternatives for patients requiring specific services while lacking insurance coverage
* Act as liaison to Population Health department in regard to chronic disease state management programs
* Facilitate as liaison to the Member Services and QI departments to address any ongoing case management issues or concerns identified via the "Voice of the Customer" Program.
* Assist in the development and implementation of new policies and procedures for the department as they relate to high-risk patient populations.
* Develop and maintain resource directory for physicians and case management staff.
* Participate in advanced care planning initiatives
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research... and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.