Social Worker, Heart Failure Clinic, Full Time, Days

Inspire health. Serve with compassion. Be the difference.

Job Summary

Accountable for managing targeted patient populations in order to achieve efficient and effective care delivery. Includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Functions as part of an interdisciplinary team to guide and track individuals across time and delivery sites. Provide social work services for targeted populations and serve as social work resource for department.

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's values : Inspire health. Serve with compassion. Be the difference
• Assists in development of an initial Plan of Care that highlights actual and potential self-management improvement opportunities.
• Facilitates and monitors implementation of Plan of Care.
• Coordinates patient / family participation in Plan of Care and self-management.
• Coordinates patient education to achieve Plan of Care.
• Performs home visits as necessary to evaluate possible barriers to attainment of self-management goals and develops strategies to overcome barriers.
• Participates in the development and execution of the Plan of Care.
• Demonstrates expertise in care management and serves as resource to the interdisciplinary health care team.
• Integrates knowledge of external and internal regulatory requirements into the review and management of cases.
• Works to provide continuity of care.
• Serves as bridge across the clinical setting.
• Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-PQRI) when coordinating and facilitating Plan of Care.
• Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice.
• Documents in the medical record and on team tools, accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals.
• Adheres to nationally accepted standards of Case Management.
• Demonstrates adaptability to new standards and to the evolution of workforce development activities.
• Performs other duties as assigned.

Supervisory / Management Responsibilities

Minimum Requirements

In Lieu Of

Required Certifications, Registrations, Licenses

Knowledge, Skills and Abilities

Work Shift

Day (United States of America)

Location

Richland

Facility

1510 Richland Hospital

Department

15106570 Heart Failure Clinic

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