• Delivers professional and thorough social work services, including psychosocial assessment and intervention planning.
  • Identifies patients who require social work assessment and intervention through high risk screening, interdisciplinary team meetings and individual referrals.
  • Conducts assessments that address bio-psycho-social issues for age, population and health specific needs which results in individualized plans of care.
  • Provides support and counseling to patients and families.
  • Provides information and assistance for identified financial or social needs.
• Coordinates complex transition plans with patients, families, health care team and community providers.
  • Utilizes the electronic medical record to monitor, document and communicate patient progress toward goals and progression of the social work plan.
  • Collaborates and communicates with interdisciplinary team anticipating needs to move the plan of care forward.
  • Provides support and information to patient and families regarding transition plan.
  • Maintains knowledge of government and private payer networks and services to assure appropriate transitions.
  • Collaborates with community and health care resources based on need to coordinate care for the patient.
• Advocates for patients and families by supporting patient rights and accessing protective services.
  • Demonstrates awareness of patient rights and ethical decision making; provides advocacy to support patient and family.
  • Assures appropriate reporting of vulnerability or suspected abuse as mandated by law.
• May participate in care system process that prevent readmissions.
  • Plans and participates in transition conferences with patients and families.
  • Utilizes tools and technology to identify and intervene with patients who are at risk for readmission.
  • Ensures that a complete clinical handoff occurs for at risk patient, which may include referrals.
• May collaborate with the health care team to promote appropriate length of stay.
  • Utilizes tools and technology to support appropriate length of stay management.
  • Facilitates timely referrals and transfers of information.

Job Requirements:

• Bachelor's degree in Social Work required or
• Master's degree in Social Work preferred
• 0 to 2 years of experience in a acute care setting preferred
• 2 to 5 years social work experience preferred
• Licensed Social Worker - MN Board of Social Work required

This position is supporting our Ambulatory Care Management Program.

Work schedule: Monday - Friday

Work Hours: 8:00AM-4:30PM

No Weekends

Location : depends on the candidate location, this position is regional

West, North, or East region. Allina Commons is the central office. This position will travel in their respective region.