Social Worker II - Ambulatory Care Management- Women and Children- Chambersburg - Day

Key Responsibilities:

• Conduct psychosocial assessments and develop care plans.
• Connect patients to resources for housing, food security, transportation, and behavioral health.
• Collaborate with care teams to improve health outcomes.
• Provide patient-centered care navigation and behavioral health support.
• Work within value-based care models to reduce emergency department use and inpatient admissions.
• Support care transitions and patient education from pregnancy through early childhood.
• Participate in case conferences, quality improvement projects, and data-driven performance monitoring.
• Emphasize culturally competent and trauma-informed care.

Essential Functions:

• Interviews patients and family members to obtain information about home environment, family relationships, health history, and patient's personality traits.
• Evaluates data gathered in terms of the medical plan of treatment, available social service programs, and plans a pertinent therapy program that will provide each patient with maximum benefit.
• Assists patients and families to understand, accept, and follow medical recommendations.
• Utilizes resources to help patient resume life in the community or to learn to live with the disability.
• Interprets nature of illness and prescribed course of treatment to patients and families. Communicates family issues to other staff members. Participates in planning conferences.
• May assist in developing discharge and post-hospital care plans and/or serve as a liaison between home care and hospital staff.
• Collaborates with other hospital programs and community agencies with which patients and families are involved.
• Performs follow-up calls and/or checks with health care and related agencies used after patient discharge.
• Prepares and maintains required documentation on each case. Records the care coordination component of care on the client's record, including the identified care problems and plans of care that have been implemented and/or suggested to the client and family where appropriate. Submits clinical documentation and records in an accurate, legible and timely manner consistent with agency policy.
• Advises the supervisory staff on community resources available to meet client needs and assists in making appropriate referrals.
• Provides care coordination consultation to the supervisory staff to enable them to assess the significant social, economical and emotional factors related to the care problem.

Common Expectations:

• Demonstrates knowledge of the principles of growth and development over the life span of the assigned patient population. Assesses and interprets patient age specific data and provides appropriate, age specific treatment. Provides direct patient care to assigned patient age group(s).
• Demonstrates a commitment to patient, visitor and staff by: complying with all applicable safety regulations; learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and "error proof" systems that will lead to increased safety; and participating in safety education programs and root cause analyses as required.
• Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Develops relationships with community agencies, groups, professional affiliations as appropriate.