Works with health care team that includes physicians, nurses, therapists, and other allied departments to care for patients. Provides appropriate assessment and interventions for the psychosocial and continued care needs of patients and families and including the recommendations of team members. Coordinates utilization of resources in the most cost-effective manner to meet patient's ongoing physical, psychosocial and continuing care needs.
Provides physicians and members of the interdisciplinary health care team with appropriate and timely biopsychosocial information related to the patient's need for medical care and evaluates the plan of care with changing conditions, additional information or upon request and referral.
Identifies patient's psychosocial needs in collaboration with the health care team and implements plan of care and appropriate intervention to meet identified needs.
Reviews medical record, interviews patient and family members or responsible party.
Discusses case with the multidisciplinary team to develop and implement appropriate interventions.
Assesses patient and family level of understanding of diagnosis and treatment and determines ability to comply with medical recommendations.
Provides intervention to maximize compliance with treatment plans.
Evaluates patient psychosocial, living situation, available supports, and incorporates treatment team recommendations for post discharge care.
Seeks clarification of information as needed and follows up on outstanding information that impacts final plans and referrals needed.
Educates patients and families of applicable resources, limitations and relevant financial issues of the services to meet patient needs.
Coordinates internal and external services to meet the identified needs of patient.
Communicates to patients, families, and multidisciplinary team in a timely manner when the changes in patient care needs require a change in the expected discharge plan, available community resources, and alternatives that are appropriate to meet the revised plan of care.
Referrals are completed to appropriate community resources in a timely manner to ensure patient discharges are not delayed due to avoidable actions.
Assists with completion of resource forms as needed to facilitate timely services to patients.
Ensures patients are offered choice of vendors in selection of referrals to meet post acute needs.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Travel to home visit when required
Experience in Nephrology and/or Transplant - preferred
Participate in a multi-center clinical trial to help patients overcome barriers to kidney transplant.
Master's Degree-Social Work (Required)
Minimum of 1 year-Related work experience (Required)
Certification(s) and License(s)
Licensed Social Worker - Default Issuing Body; Valid Driver's License - Default Issuing Body
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13... hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.