Social Worker MSW, Care Management -PRN - PHH **RESPONSIBLE FOR: ** The Social Worker strives to promote patient and family wellness, improved care outcomes, access to appropriate hospital and community resources, and manages, supports and develops comprehensive transitional care plans for patients with complex and psychosocial needs in Inpatient and Emergency Department (ED) environments. 1. Assesses, evaluates, plans and coordinates community services 2. Advocates for services to meet the specific patients / family complex needs 3. Conducts high risk assessments within timeline required by departmental and regulatory guidelines 4. Coordinates with Care Manager daily 5. Conducts psychosocial assessments 6. Provides patients / family members with Community Resources 7. Coordinates the transition to post-acute care services (Hospice, Home Health, Skilled Nursing Facility, etc.) 8. Coordinates as needed with other members of the care team 9. Organizes family meetings and/ team conferences 10. Works with the treatment team to provide solutions for complex cases (i.e. Behavioral Health and/or barriers to discharge) 11. Identifies high risk patients based on standardized criteria 12. Coordinates appropriate reporting to legal agencies as needed with respect to abuse and neglect 13. Facilitates the coordination of financial assistance as needed 14. Identifies and documents quality variances and/or barriers to discharge 15. Provides post discharge follow-up as appropriate to ensure continuity of care/services 16. Participates in PHC readmission management initiatives MINIMUM EDUCATION REQUIRED: Master's degree from an accredited social work program required MINIMUM EXPERIENCE REQUIRED: None. MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW: None ADDITIONAL QUALIFICATIONS: Prefer a minimum of two (2) years of experience in an acute or post-acute setting. Licensed master social worker (LMSW) in state of Georgia preferred. **Primary Location: **United States-Georgia-Stockbridge-1133 Eagles Landing Parkway **Work Locations: ** **Job: **Social Work **Organization: **Piedmont Healthcare **Schedule: **PRN **Job Posting: **Dec 31, 2018, 8:40:02 PM **Shift: **Day Job