POSITION SUMMARY:
The Social Worker / Social Work Assistant is a direct-service professional providing essential case management, psychosocial assessment, client advocacy, and service coordination within Marianas Health Services. Depending on academic credentials, the incumbent will function as either a Social Worker (holding a BSW) or a Social Work Assistant (holding a related bachelor's degree in Human Services, Psychology, Rehabilitation, Sociology, or a related field) operating under the supervision of a Master of Social Work (MSW). This role involves identifying and addressing clients' holistic needs, linking them to community resources, and coordinating care across interdisciplinary teams. The incumbent is responsible for meticulous documentation, strict confidentiality, and regulatory compliance, promoting patient well-being and mitigating social barriers to treatment. The position requires close collaboration with the MSW supervisor and interdisciplinary healthcare providers consistent with generalist practice standards.
DUTIES AND RESPONSIBILITIES
The duties focus on direct-service casework, advocacy, and service coordination, avoiding duties that require specialized clinical licensure.
● Psychosocial Assessment and Intake: Conduct initial intake interviews and timely psychosocial assessments to identify client needs, immediate safety risks, strengths, and existing support networks. This includes gathering information about clients' circumstances related to issues such as housing, employment, substance use, financial status, and mental health resources. Evaluates prospective clients for appropriateness of social work services and communicates intake status to the Case Management team.
● Resource Linkage and Advocacy: Research, refer, and advocate extensively for clients’ rights, decisions, and needs, ensuring access to relevant external community resources, public assistance, and ancillary support services (e.g., food security, transportation, childcare). This often involves introducing clients to service providers and agencies and assisting with enrollment processes.
● Service Planning and Monitoring: Collaborate with clients, families, and the interdisciplinary team (e.g., physicians, nurses, Clinical Manager) to develop, implement, monitor, and amend individualized case management service plans. These plans must be based on meaningful assessments and shall have specific, attainable, and measurable objectives promoting the client’s overall well-being and ability to cope with life challenges, such as illness or unemployment.
● Crisis Response and Support: Respond to client crises or emergencies (excluding the independent diagnosis of psychological disorders or provision of psychotherapy) by providing immediate supportive counseling, facilitating communication with the medical team, and making appropriate, timely referrals for specialized mental health, substance abuse, or protective services. Facilitates the reporting process when concerns arise about patient safety, abuse, neglect, or intimate partner violence, utilizing established community resource listings.
● Documentation and Case File Integrity: Maintain accurate, timely, and confidential electronic case files and documentation, strictly adhering to agency policies, HIPAAregulations, and required standards for audit readiness. This includes preparing and evaluating case reports detailing the initial assessment, the care plan, and follow-up actions for individual clients.
● Interdisciplinary Coordination and Liaison Services: Serve as a critical liaison between clients, families, providers, specialists, and community agencies. The incumbent is responsible for coordinating referrals to outside agencies and assuring accurate and timely information reaches all involved parties, ensuring continuous and coordinated care, especially during transitions (e.g., hospital discharge to home or long-term care).
● Setting-Specific Case Management and Unit Coordination: Provide essential dual-focused support to both the Homecare Unit and the Outpatient Clinic (Sagan Hinemlo Family Clinic), adjusting priorities based on the client's setting and stage of care.
● Homecare Unit Focus: Focus on complex, long-term psychosocial management, environmental support, and stabilization for patients managing chronic conditions or recovery at home.
○ Transition/Discharge Planning: Coordinate the care of patients moving from a hospital or clinic back into their home setting, reviewing new admissions for special needs that impact in-home care delivery, and setting up services prior to discharge.
○ Environmental Assessment: In collaboration with the clinical team, conduct in-home assessments to identify social determinants of health (SDOH) issues, such as lack of food security, unsafe housing conditions, or other hazards that influence in-home recovery.
○ Long-Term Support: Provide ongoing assistance to patients and families coping with the emotional, financial, and social burdens associated with chronic or severe illness.
● Outpatient Clinic Focus: Focus on immediate resource access and stabilization for clients accessing ambulatory services.
○ Ambulatory Assessment: Conduct initial screenings for new clinic patients to identify immediate resource needs (e.g., prescription assistance, transportation) to ensure adherence to treatment plans.
○ Liaison Services: Serve as a primary point of contact for external community services, helping coordinate appointments and information flow between the clinic, specialists, and community resources.
● Performs other duties as assigned
