LSW – Licensed Social Worker – Geisinger at Home Care Transition

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: Masters 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

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

Masters Degree-Social Work (Required)

Experience

Certification(s) and License(s)

Licensed Social Worker – 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 know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.

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.