Job Summary

The Social Worker serves as a liaison between hospital, Geisinger at home, Care Coordination & Integration, and community agencies for the exchange of clinical and referral information. Interacting with Geisinger Health Plan lines of business and Keystone Accountable Care Organization members, patient support systems, interdisciplinary inpatient and outpatient health care professionals, and community and state agencies. Identifies high risk patients from a psychosocial/financial perspective, assesses the psychological needs of patients and support systems, providing information, support, counseling, care management, and referrals to appropriate resources. Collaborates with the interdisciplinary health care professionals to ensure patient needs are met and care delivery is coordinated across the continuum to optimize discharge planning home in a timely manner. Resolves psychosocial patient care issues and develops and implements a complex patient transition/discharge plan. Collaborates with onsite Geisinger at Home Registered Nurse Case Manager to implement home-based model of health care in discharging planning.

Job Duties

• Collaborates with inpatient and outpatient Case Management healthcare professionals in development of personalized, timely, and safe discharges home.
• Identify and resolve barriers to Geisinger Health Plan (GHP) lines of business and Keystone Accountable Care Organization (KACO) members returning home from hospitalization.
• Participates in the screening and identify appropriate members for Population Health Management.
• Identifies and provides support in addressing social determinates of health.
• Participates in daily interdisciplinary team meetings inpatient at Geisinger Facilities and collaborate with inpatient team in development of a plan of care for Population Health Management established/potential patients.
• Monitoring of GHP & KACO members patients while admitted to Geisinger Facilities.
• Screening, engaging, and scheduling of home visits at bedside to optimize transition of care process.
• Incorporates Geisinger at Home Registered Nurse Case Manager to implement home-based model of health care in discharging planning.
• Engaging with members at bedside.
• Communicating with patient family/caregivers at bedside or phone call in efforts to optimize timely discharge planning.
• Complete/continue advanced care planning discussions at bedside.
• Initiates and monitors completeness, accuracy, and timeliness of all documentation.
• Provides documentation of initial assessments and reviewing of all referrals for accuracy and content prior to discharge.
• Reports potential risk or quality management.
• Escalates issues to resource as necessary to resolve barriers through appropriate administrative and medical channels.
• Collaboration with behavior health managed care organization regarding GHP Family Plan Holders.
• Collaborates with outpatient interdisciplinary patient care professionals to update on discharge planning.

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.

Position Details

Hours: Monday through Friday; 8-hour shifts; 8:00a-4:30p

Education: Master's Degree is Social Work is required; Licensed Social Worker is required

Experience: 2 years’ experience with Advanced Care Planning and Family Decision Making is preferred

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Geisinger cares about not only its patients and members, but also about you and your family. We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally. We believe in creating a diverse and inclusive environment where all employees can be their authentic selves. To learn more: https://jobs.geisinger.org/diversity

• Full benefits (health, dental and vision) starting on day one
• Three medical plan choices, including an expanded network for out-of-area employees and dependents
• Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA)
• Company-paid life insurance, short-term disability, and long-term disability coverage
• 401(k) plan that includes automatic Geisinger contributions
• Generous paid time off (PTO) plan that allows you to accrue time quickly
• Up to $5,000 in tuition reimbursement per calendar year
• MyHealth Rewards wellness program to improve your health while earning a financial incentive
• Family-friendly support including adoption and fertility assistance, parental leave pay, military leave pay and a free Care.com membership with discounted backup care for your loved ones
• Employee Assistance Program (EAP): Referrals for childcare, eldercare, & pet care. Access free legal guidance, mental health visits, work-life support, digital self-help tools and more.
• Voluntary benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life and pet and legal insurance

Education

Master's Degree-Social Work (Required)

Certification(s) and License(s)

Licensed Social Worker - Default Issuing Body

Skills

Assessment And Diagnosis; Behavioral Therapy Management; Psychotherapy; Organizing; Patients Rights; Working Independently; Social Work; Intake Assessments

About Geisinger

Founded more than 100 years ago by Abigail Geisinger, the system now includes ten hospital campuses, a 550,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,700 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and Twitter.

Our Commitment to Diversity, Equity and Inclusion

Geisinger values who you are, where you are from, and where you are going. We seek out people of various backgrounds and cultures with unique abilities, non-traditional career paths and ambitious aspirations. 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. Read more about Our Commitment to Inclusive Recruiting.

Our Vision & Values

Everything we do is about making better health easier 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.

Our Benefits

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.