Job description

Major Responsibilities:
Performs culturally responsive psychosocial screening and assessment to identify social, psychological, behavioral, economic, and environmental needs of outpatients and their families. May include family needs assessment, assessment of safety and environment risk, and assessment of resource needs.
Develops goals related to the social, psychological, behavioral, economic, and environmental needs of the patient and family, and in alignment with the patient’s overall health goals. Identifies potential risks and barriers to positive health outcomes. Identifies other necessary resources and services both within the health care system and the community which may include safety planning.
Provides appropriate social work and therapeutic interventions to facilitate the execution of the social care plan. Includes psychosocial and supportive counseling, health behavior coaching, motivational interviewing, psychoeducation and health literacy, case management, and crisis intervention services.
Provides education to patients and families regarding Advance Care Planning for health care decision-making and assists with the execution of those documents as necessary.
Facilitates safe and effective transitions to home and community. Facilitates smooth handoffs to other professional and community support providers. Assists with problem-solving and resolution of barriers to access to care. Incorporates systemic and solution-focused approach to case management and care coordination.
Serves as integral member of health care team supporting team-based approach to care management. Provides effective communication and collaboration with team members.
Provides patient navigation and advocacy services. Participates in outpatient care management initiatives as well as strategies aimed at enhancing the patient experience and improving clinic and department quality.
Participates in research activities. Adheres to evidence-based and industry best practices for professional social work. Adheres to the social work professional code of ethics and demonstrates decision-making based on ethical principles. Documents social work activities in accordance with department protocols and standards and in keeping with all relevant federal and state regulations.
Provides strength-based, social work services to diverse patient populations using a cultural humility framework and grounded in principles of trauma-informed care.
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and/or Certification Required:
Social Worker license issued by the state of Wisconsin.

Education Required:
Master's Degree in Social Work.

Experience Required:
Typically requires 1 year of experience in providing social work services within a complex care system.
2-3 years of experience in our local community preferred

Knowledge, Skills & Abilities Required:
Demonstrated knowledge of social work principles and methods, and the ability to apply these in a health care setting.
Demonstrated decision-making, team building, time management, customer service, and conflict resolution skills.
Excellent oral and written communication skills.
Intermediate computer skills including word processing, presentation applications and electronic mail.
Demonstrated organization and time management skills.
Ability to work with a multidisciplinary team.
Self starter with the drive and motivation to help our patients and be a liaison to our clinic is assisting with how patients navigate barriers they face in receiving healthcare
Communication and professionalism

Physical Requirements and Working Conditions:
Generally exposed to a patient care environment.
May be exposed to mechanical, electrical, chemical, and radiation hazards as well as blood and body fluids; therefore, personal protective equipment must be worn as necessary.
Must sit, stand, speak, read/write, and walk throughout the workday.
Position may require travel; therefore may be exposed to road and weather hazards.
Operates all equipment necessary to perform the job.
Must be able to lift up to 20 lbs. and use repetitive activities of the fingers, hands and wrists.
Must have functional sight and hearing.

Additional Information
Our social worker works along side an RN to support our clinic through our Patient Assistance Program.
They assist patients with local, state and national resources to help our patients live well. The clinic will refer patients who need medication assistance (not taking rx as prescribed due to cost or ability to manage medications on their own), Transportation assistance, patients that may be mistreated (domestic violence, neglect abuse, etc…), Patients who need food, clothing, housing, in home care needs or patients who may need SSDI.
Our social worker an RN work in tandem to support these patients and help them navigate the complexities of applying for these programs.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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