Responsible for participating in the development and implementation of social work service plans to address client's identified needs including agency referral or other follow up care to ensure optimal utilization of resources.
- Must have a Bachelor Degree in Social Work.
- Must be licensed by the Texas State Board of Social Work Examiners.
Skills or Special Abilities
- Must be able to communicate effectively with a diverse population of patients, medical and nursing staff and community agencies both orally and in writing.
- Must be able to demonstrate a working knowledge of community agencies and services available for the special needs of assigned patients.
- Must have excellent interpersonal skills.
- Must demonstrate patient centered/patient valued behaviors.
- Virtual Care Only:
- Bilingual Spanish speaking preferred.
- Confident with technology, specifically electronic medical record, video encounters and computer applications.
- Must be able to work collaboratively and optimally with patients with serious health conditions and barriers to care.
1. Completes psychosocial assessment of patient's needs by interviewing patient, family and medical staff to determine needs and plan for services.
2. Assists with implementation of psychosocial screening process that includes daily review of completed psychosocial screening forms in an effort to identify and address needs in a timelier, efficient manner. Utilizes information obtained from the psychosocial screenings to develop a plan of action.
3. Develops and implements a case management plan that is consistent with the intensity of the problem, risks and available support for each patient.
4. Develops and maintains knowledge regarding eligibility guidelines, referral and intake processes in order to successfully link patients to needed resources. Develops and maintains relationships with resource and community agencies to ensure effective communication among and between patient, family, community agency, and medical provider. Coordinates with all parties involved to ensure service delivery and effective use of resources.
5. Develops and facilitates health education classes that promote prevention, early intervention and wellness topics to ensure information is available.
6. Participates in social work meetings, social work peer reviews, observational peer reviews and other activities that promote clinical and professional development, quality, and patient satisfaction. Seeks guidance as needed and uses supervisory feedback and guidance to improve work methods.
7. Completes documentation for the medical record that is timely, objective and demonstrates an accurate chronology of services provided.
8. Compiles and submits accurate statistical information into needed reports and in a timely manner.
9. Takes the initiative to identify patients/families in need of service and responds to referrals in a timely manner that reflects efficient and productive service delivery.
10. Works with patients to problem solve and implement a plan of action for situational crises as needed.
11. Provides needed coverage to ensure services are delivered and available that meets patient/family needs and program demands.
12. Stays abreast of the latest developments, advancements, and trends in the field of social work by attending seminars/workshops, reading professional journals, actively participating in professional organizations, networking with other professionals in the field and maintaining licensure. Integrates knowledge gained into current work practices.
13. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the Social Work and COPC clinics/programs. Develops effective internal controls that promote adherence to applicable state/federal laws, and the program requirements of accreditation agencies and federal, state, and private health plans. Seeks advice and guidance as necessary to ensure proper understanding.
14. Identifies ways to improve work processes and improve customer satisfaction. Modifies approach, communication and interaction to take account of sensory impairments and specific needs of all customers, in particular older adults. Makes recommendations to supervisor, implements and monitors results as appropriate in support of the overall goals of the department and PHHS.
15. Virtual Care Only:
a. Maintains directory of community resources.
b. Provides proactive virtual outreach to patients to assist in identifying social determinants of health, barriers to care, provides linkage to appropriate community resources, and facilitates referral to other services through collaboration with VCO team to improve health care outcomes and reduce organizational utilization.
c. Serves as a point of escalation for VCO team to assess social determinants of health and coordinate assistive community and organizational resources.
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.
Nearest Major Market: Dallas
Nearest Secondary Market: Fort Worth
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