Licensed Clinical Social Worker

Essential Job Duties

• Conduct telephonic screenings and assessments, addressing clinical, behavioral, and socioeconomic needs of post-discharge patients.
• Identify and proactively communicate with patients with particular risk factors and diagnoses to investigate for likelihood of readmission (assess condition status, monitor for clinical deterioration, assess level of self-care and support systems) and initiate post-hospital services as needed.
• Serve as a liaison between the patient and the care team, and advocate on behalf of the patient/family/caregivers for access to services that support the patient’s preferences, quality of life, and safety and well-being.
• Reassess and respond to changes in physical, behavioral, and psychosocial circumstances, as needed.