HCA Physician Services Group

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Medical Social Worker - PRN (Days & Weekends)

at HCA Physician Services Group

Posted: 3/2/2019
Job Status: On Call
Job Reference #: 08224-64551

Job Description

St. David's North Austin Medical Center is part of St. David's HealthCare, one of the largest health systems in Texas, which was recognized with a Malcolm Baldrige National Quality Award in 2014. The 378-bed multi-specialty, acute care facility is dedicated to the highest level of women's health services, including maternity and newborn care with Level I, II and III nurseries at the adjacent St. David's Women's Center of Texas. The facility also features a 24-hour emergency department, the Texas Institute for Robotic Surgery, the Bariatric Center, heart and vascular center, neurology and neurosurgery, a kidney transplant program, inpatient and outpatient surgery, and acute inpatient and outpatient rehabilitation, among many others. St. David's North Austin Medical Center is also home to St. David's Children's Hospital. In 2012, 2013, 2015 and 2016, the hospital earned a national distinction for patient safety from The Leapfrog Group.



Under general direction, provide Medical Social Work services to patients and families. The Social Worker assists the patient/family to achieve an effective transition from hospital to post-hospital care through psychosocial evaluation, counseling, information and referral, patient education, and assistance with discharge planning. The Social Worker is also responsible for assisting with policies and procedures, record keeping and reporting, performance improvement, and interfacing with other hospital units, community service agencies, chemical dependency and psychiatric treatment facilities. Assists patients and families in understanding normal responses to illness and resulting lifestyle changes.

The Social Worker will evaluate the psychosocial needs of patients and family support systems and will coordinate appropriate discharge plans for identified patient populations. The Social Worker acts as a liaison between the facility and resources external to the organization. He/she will facilitate implementing timely discharge plans and facilitate follow-up to anticipated post-acute interventions identified in the plan of care. The Social Worker will provide crisis intervention and support. The Social Worker will assist the Case Manager in facilitating patient transition across the continuum of care and will identify and track barriers to patient throughput. Participates in providing patient specific care standards as directed, and follows service excellence standards to ensure high levels of patient satisfaction.




  • Performs a comprehensive assessment of psychosocial needs of assigned patients; Involves patient, family/responsible/significant others, develops, implements, monitors and revises plan of care in collaboration with the interdisciplinary team
  • Assesses patients discharge needs and facilitates the provision of services necessary to meet identified needs; performs home health referrals, intermediate care and skilled nursing facility referrals, assist patients with medication acquisition, facilitates follow up appointments, arranges public transportation, etc.
  • Evaluates suspected abuse and neglect referrals; makes official reports to state and regulatory or legal agencies as required by statue or facility policy
  • Develops an individual plan of care for recurring patients to include education related to accessing healthcare services at the appropriate level of care; preventative education, and community based resources, provides assistance with access to medication assistance programs
  • Provides education to the under-resourced patient/family of potential and available resources; identifies needs, coordinates the development of realistic plans which include patient/family centered goals, facilitates implementing plan, and performs follow-up evaluation
  • In collaboration with the interdisciplinary team, develops, implements, evaluates, revises as needed, a discharge plan to include identified psychosocial and discharge needs
  • Documents professional recommendations, care coordination interventions, and case management activities to effectively communicate to all members of the health care team
  • Participates with the interdisciplinary team to ensure psychosocial and discharge needs are addressed; plan, interventions and patient/family/MD concurrence will be documented
  • Acts as a liaison through effective and professional communications between and with physicians, patient / family, hospital staff, and outside agencies
  • Demonstrates knowledge of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives as it relates to the provision of Case Management Services
  • Makes appropriate referrals, after collaboration with the Case Manager, to third party payer disease and case management programs for recurring patients and patients with chronic disease states
  • Facilitates patient throughput with an ongoing focus on quality outcomes and an efficient transition between levels of care
  • Tracks and trends barriers to care; makes recommendations and develops action plans to improve processes and systems
  • Provides psychosocial support to patients and families
  • Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered
  • Acts as an advocate for identified needs and makes appropriate referrals; abuse and neglect, substance abuse/overdose, homelessness, post-partum patients < 17 years of age, fetal demise, mother-baby bonding, adoptions, guardianship, etc.
  • Acts as a liaison between the facility and community resources to enhance community outreach coordination; establishes and maintains resource database, educates peers and patients on resources, performs community outreach as directed
  • Tracks and trends variances barriers related to access to care; makes recommendations and develops action plans to improve processes and systems
  • Adheres to established policy and procedure and standard of care; escalates issues through the Chain of Command
  • Facilitates delivery of Patient Information and Choice Letter to assure documentation of patient/family involvement with discharge planning and hospice of post-discharge service providers.
  • Facilitates the ordering and delivery of specialized medical equipment, orthotics and prosthetics as ordered by the attending physician.
  • Completes Orders of Protective Custody (OPC) during office hours and works with the Crisis Intervention Team (CIT) for Peace Officer Emergency Commitment (POEC) outside regular business hours and at weekends.
  • Ensures timely communication of relevant psychosocial information to physician and other identified significant care providers in order to facilitate appropriate patient care in the hospital and anticipated needs at discharge.
  • Assists in reviewing and revising social work policies and procedures in accordance with hospital and regulatory standards at least triennially.
  • Working knowledge of Joint Commission standards, UR/QA and other regulatory agency standards related to social services and discharge planning.
  • Attends meetings as required of Case Management and or Department Director. Attends and actively participates in monthly staff meetings, and attends called departmental meetings when necessary. Attends and participates in facility committees, employee forums and departmental meetings as requested.
  • Actively utilizes and complies with facility principles of good communication and customer service standards, including use of AIDET and KWAKT as developed by the department.
  • Maintains compliance with required licensure, ethics and compliance training, annual employee health initiatives, and mandatory education as required.
  • Social Worker responds to all referrals within 24 hours
  • Prepares and presents in-service and training programs as requested.
  • Employee's conduct must reflect the Company's values and a commitment to the Code of Conduct ethics and compliance program.
  • Employee reflects SDH Service Excellence standards in every interaction.



Required: Master's Degree in Social Work from a school of Social Work accredited by the Counsel of Social Work Education. Three years Social Work experience


Preferred: Hospital and/or acute care case management experience



Required: Current Texas licensure; LCSW, LMSW


Preferred: BLS certification. Certification in Social Work or Case Management, LCP


Reports to:      Manager and Director of Case Management