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MSW for Continuous Care (On site)

Location: Teaneck, NJ, United States
Date Posted:



Holy Name is New Jersey's last remaining independent, Catholic health system, comprising a comprehensive 361-bed acute care medical center, a cancer center, medical fitness center, residential hospice, nursing school, and physician network. The system has a national reputation for providing culturally sensitive care to a diverse population, drawing patients from across the New York City region to its specialty centers and renowned doctors. Holy Name's mission to provide technologically advanced, compassionate and personalized care extends across a continuum that encompasses education, prevention, diagnosis, treatment, rehabilitation and wellness maintenance. The system is known as a high-quality, low-cost provider of extraordinary clinical care given by compassionate, highly trained physicians and staff.

A Brief Overview
The Social Worker/Care Coordinator is responsible for facilitating and coordinating services for patients through the continuum of care that ensures quality care in the most cost efficient manner on assigned units or teams. Assist patients and their families in understanding illness and disabilities. They help resolve personal, financial, and environmental difficulties which interfere with obtaining maximum benefits from care. Makes appropriate referrals and arrangements to help patients/families achieve a safe discharge plan of care. Assist in coverage of specialty areas, such as Labor and Delivery, Pediatrics, Intensive Care Unit, Clinic and Emergency Department. Assignments vary based on departmental need and coverage.

What you will do

  • Performs timely new admission screening and interviews with patients and families to assess and evaluate patient's social, psychological and environmental situations. Reviews patient information obtained from physician, staff and medical records to determine patient's needs
  • Provides social work services in accordance with the assessment and diagnosis. Conducts individual/group treatment and information sessions for patients and families with personal and environmental difficulties which may interfere with obtaining maximum benefits from medical/psychiatric care
  • Directs patients and families to appropriate community agencies and resources for financial assistance, counseling, rehabilitation, auxiliary care and long term care via written and oral communication
  • Conducts complex discharge planning for patients with serious disabilities or illnesses, assessing needs for more specialized care and arranges placement in other health care facilities, rehabilitations or extended care facilities as needed.Including but not limited to obtaining and processing all necessary information to submit EARC-PAS to above mentioned facilities
  • Arranges ambulance transportation as needed for patients prior to discharge or transfer to another facility
  • Participates as an active, informative and cooperative team member of the health care staff by attending discharge rounds for case finding/follow up and participating in the discharge plan while acting as an advocate for the patient. Arranges family meetings to assist in discharge planning as indicated
  • Legibly documents social work assessment and interventions in a timely manner in patient's medical records according to department policy
  • Attends daily discharge rounds and weekly interdisciplinary rounds on respective units
  • Contributes any new found resources and knowledge with fellow social workers
  • Assist in Quality Improvement projects specific to the department
  • Maintains and manages Transfer database requirements for statistical analysis of data
  • Maintains a knowledge of resources available in the community for patients and their families
  • Contacts proper agency for suspected child abuse, elder abuse and domestic violence referrals
  • Arranges hemodialysis for new and existing hemodialysis patients
  • Provide copy IM letter to patients with 48 hours of discharge
  • Refers patients to financial counselors if indicated
  • Accepts and completes additional responsibilities as directed

Education Qualifications

  • MSW Required and
  • Compliance with continuing education requirements as mandated by the State Licensing Board Required

Experience Qualifications

  • 1-3 years 1-3 years experience in hospital health care setting Required

Knowledge, Skills, and Abilities

  • Analytical and problem solving along with excellent verbal and written communication skills

Licenses and Certifications

  • Valid New Jersey Social Work License (LSW) Upon Hire Required
  • BCLS - Basic Life Support American Heart Association Upon Hire Required

Holy Name is a mission-driven facility whose quality standards and philosophy are rooted in the principles of its founders, the Sisters of St. Joseph of Peace. Those principles are exercised daily by the Medical Center's dedicated and talented team of physicians, nurses, allied health employees, and a wide variety of non-clinical administrative and operational staff members. Holy Name is an Equal Opportunity Employer.