Job Description

This can be a full-time position. This position is responsible to provide social work services for an assigned patient caseload, to facilitate patient admissions and/or initial psychosocial assessments, and/or to make visits on an assigned basis across Transitions service lines as directed by the Team Leader. The schedule for this position is Monday-Friday 8:30am-5:00pm; rotating weekends; 1 major or 2 minor holidays per year.

Responsibilities what you do

• Provide psychosocial assessments of patients and families to identify emotional, social, cultural, financial and environmental strengths and problems related to their diagnosis, illness, treatment, and life situation.

• Support patient/family’s individual spiritual/cultural beliefs by assessing for cultural issues; developing culturally sensitive care plan and collaborating with interdisciplinary team in provision of culturally sensitive care.

• Formulate, develop, and implement a comprehensive psychosocial plan of care utilizing appropriate clinical social work treatments and intervention, while maintaining the dignity of the patient.

• Responsible for documenting assessments, care plans, interactions, and interventions according to regulatory standards and agency standards for service lines associated with the identified patient.

• Maintain awareness of patient payer source and assist the finance department in collecting accurate insurance information, including facilitating self-pay patients through the appropriate financial screening process (i.e. Medicaid, Charity Care,).
• Educate patients, families and referral sources on various levels of hospice care.
• Maintain a working knowledge of the Condition of Participation (COP’s) and other regulatory requirements affiliated with the Transitions service lines you are working within.

• Works collaboratively with IDG and other Transitions LifeCare (TL) departments in achieving patient care goals.

• Participate in IDG care teams and provide leadership in representing clinical social work perspective/liaison with patient and family.

• Provide appropriate education on hospice philosophy and services to potential new patients/family members/ and/or referral sources.

• Admit patients to hospice, in congruence with TL policies and procedures and relevant regulatory standards and conditions of participation.
• Provide education to patients and families around issues related to adaptation to the patient's diagnosis, illness, treatment and/or life situation.

• Collaborates with facility staff and other Interdisciplinary Group (IDG) members to determine the patient’s level of care and coordinate the appropriate utilization of contract services.

• Participate in the identification of clinical or operational performance improvement opportunities and in performance improvement activities

• Actively participates in the orientation and training of new employees of all disciplines.

• Keep current with social work and health care developments and seek to increase further enhancement of job-related knowledge.
• Maintain working knowledge of and liaison with community agencies and resources; assessing and referring patient/family to appropriate resources.

• Responsible for professionally managing time, people and technology.
• Performs other duties as assigned by supervisor.

Expectations how you do it

• Model professionalism and empathy by consistently demonstrating compassion, respect, teamwork, and dedication in all interactions with coworkers, customers, and partners.
• Adhere to all TL policies, procedures, and organizational guidelines, ensuring compliance in daily work and decision‑making.
• Deliver care and services in accordance with ACHC Standards and Medicare Conditions of Participation when applicable to your role.
• Comply with all relevant state and federal laws, regulations, and professional standards within your defined scope of responsibility.
• Promptly communicate concerns, issues, or potential risks to your immediate supervisor or another member of the management team to support a safe and effective work environment

Requirements what you need

• Master of Social Work from an accredited university
• Minimum one-year experience in health-related field (experience may include social work internships in a health care related organization).
• LCSW required within 3 years date of hire
• Knowledgeable about reimbursement sources, Medicare regulations, licensing laws, and accreditation standards.
• Strong commitment to agency wide DEI improvement efforts
• Competent computer skills
• Must have reliable transportation.

• Must be able to travel to, enter and function in the homes/facility of any patient/family in the service area to assess and provide care to all patients.
• May be required to lift and/or carry items up to 25 pounds.
• Must have abilities to complete physical assessment, communicate with patient/family care providers and physician and to complete the reporting and follow-up documentation responsibilities of the job.
• Work hours and days including weekend and holiday commitments as outlined in Employee Information Agreement.