Pool Social Worker, LCSW- Outpatient

The Social Worker provides counseling and support to help patients and families cope with medical conditions, participate in care planning, and maximize the benefits of treatment.

Key Responsibilities

• Coordinate transitions of care for patients with significant psychosocial needs.
• Maintain knowledge and liaisons with local, state, and federal services to educate and assist families.
• Ensure accurate and timely data entry into information systems.
• Collaborate with Care Coordinators and the interdisciplinary team to develop and review comprehensive care plans, including discharge planning and psychosocial assessments.
• Actively participate in multidisciplinary rounds or huddles to communicate the psychosocial impact on care transitions.
• Monitor progress toward established goals, revising plans as needed based on changes in the patient's condition.
• Assess potential obstacles to reintegration into the community, escalating concerns for resolution.
• Provide brief crisis counseling and therapeutic interventions to improve healthcare literacy and address social deficits.
• Conduct daily multidisciplinary rounds to support patient outcomes and reduce readmissions.
• Facilitate complex discharge planning through clinical social work interventions.
• Assess high-risk patients via independent case-finding or referrals and develop short-term treatment plans.
• Lead patient and family meetings to address healthcare decisions, discharge planning, and other key outcomes.
• Provide charity and financial resources and advocate for vulnerable populations.
• Serve as a subject matter expert on abuse, neglect, intimate partner violence, human trafficking, and related issues.
• Participate in clinical performance improvement initiatives and research.
• Deliver mental and behavioral health services, including crisis intervention, motivational interviewing, and evidence-based assessments.

Technical Knowledge, Skills, and Abilities

• Understanding of effective communication and teamwork principles necessary to coordinate care with the healthcare team.
• Ability to clearly interpret and communicate complex patient and family needs to the healthcare team.
• Competence in accessing, mobilizing, and coordinating family and community resources.
• Capability to educate patients and families on available resources and care plans.
• Aptitude for evaluating patient and family psychological needs and tailoring interventions.