Social Worker 3 (Multiple Positions)

Job description

The Department of Social Work at SUNY Downstate Health Sciences University is seeking a full-time TH Social Worker III.
Job Summary
The TH Social Worker III is an integral member of the hospital’s multidisciplinary healthcare team, providing professional social work services to patients, families, and caregivers. The incumbent assesses psychosocial, emotional, socioeconomic, and environmental needs; develops and implements appropriate interventions; and collaborates with the interdisciplinary care team to support patient well-being, continuity of care, and safe, timely discharge planning.
The Social Worker provides crisis intervention, supportive counseling, patient and family education, advocacy, and referrals to community resources while assisting patients and families in addressing challenges associated with illness, hospitalization, treatment, and transitions of care. Services may be provided across inpatient, outpatient, emergency, pediatric, and other specialty care settings, consistent with professional licensure, assigned responsibilities, and hospital policies.
Key Responsibilities & Duties
• Conduct psychosocial assessments of patients and families to identify emotional, behavioral, social, financial, and environmental factors affecting health, treatment, recovery, and discharge planning.
• Develop, implement, and evaluate individualized psychosocial intervention plans in collaboration with patients, families, caregivers, and the interdisciplinary healthcare team.
• Provide supportive counseling, crisis intervention, grief and bereavement support, and appropriate psychosocial interventions within the scope of professional licensure and supervision.
• Participate in interdisciplinary rounds, multidisciplinary huddles, case conferences, and care planning meetings to address psychosocial concerns and discharge needs.
• Collaborate with physicians, nurses, case managers, rehabilitation professionals, and other healthcare providers to facilitate coordinated, patient-centered care.
• Assist with safe, appropriate, and timely discharge plans, including coordination of home care, durable medical equipment (DME), community services, and post-acute care placements.
• Coordinate with Care Management and external agencies on referrals and placements to skilled nursing facilities, subacute rehabilitation, long-term care, and other appropriate settings.
• Identify psychosocial barriers that may contribute to avoidable admissions, prolonged length of stay, delayed discharge, or preventable readmissions; collaborate with the team to address them.
• Educate and advocate for patients and families regarding treatment-related needs, financial assistance, public benefits, healthcare coverage, and community support programs.
• Assist patients and families in accessing appropriate Medicare, Medicaid, federal, state, and community resources.
• Assess and respond to suspected child abuse, elder abuse, neglect, domestic violence, and other vulnerable patient situations; complete required reporting and referrals in accordance with law and hospital policy.
• Coordinate, as appropriate, with the Administration for Children’s Services (ACS), Adult Protective Services (APS), and other community agencies.
• Facilitate patient and family conferences to address psychosocial concerns, treatment decisions, discharge planning, and continuity-of-care needs.
• Assist with guardianship referrals in collaboration with Risk Management, Legal Affairs, and other appropriate departments.
• Provide psychosocial assessment, crisis intervention, and discharge planning support in emergency and other assigned clinical settings.
• Provide age-appropriate psychosocial support and care coordination for pediatric, adolescent, adult, and geriatric populations, as applicable to the assigned service.
• Document assessments, interventions, referrals, and care coordination accurately, promptly, and confidentially in the electronic medical record; complete case closure within departmental timeframes.
• Support organizational goals for effective transitions of care, appropriate utilization of resources, and length-of-stay management through interdisciplinary collaboration.
• Participate in professional development, departmental meetings, in-service education, and quality improvement initiatives.
• Comply with applicable federal and state regulations, professional standards, accreditation requirements, and hospital policies.
• Perform other duties as assigned, consistent with professional licensure, qualifications, and institutional needs.

Duties
• Assist the social worker in overall coordination for mental health and social services for patients of SUNY Downstate Primary Care Ambulatory Care Department
• Assist the medical team with assessing the psychosocial needs of patients and refer them to appropriate social services and behavioral health services. internal or external, as needed
• Engage family members/caregivers to discuss patient status and provide supportive counseling and guidance where indicated.
• Assist patients with obtaining durable medical equipment, medications, medical supplies and all -other services that will improve patient home environment and self-management abilities.
• Connect and reconnect patients to long term care services such as Managed Long-term Care Plan (MLTC), FIDA, MAP, HARP programs.
• Collaborate In a team-based care model with all members of the patient care team including PCPs, nursing, behavioral health and support staff.
• Receiving warm hand offs from PCPs, nurses and other clinicians.
• Providing feedback to PCPs on a regular basis In regards to the status of the patient and all Interventions provided.
• Conduct a face to face and phone contacts with patients
• All other tasks as assigned

Required Qualifications
• Master’s Degree in Social Work (MSW) from a program accredited by the Council on Social Work Education (CSWE), or equivalent education accepted by the New York State Education Department for social work licensure.
• Current New York State Licensure as a Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW).
• Knowledge of professional social work principles, including psychosocial assessment, crisis intervention, supportive counseling, patient advocacy, and care coordination.
• Knowledge of discharge planning principles, community resources, and social service programs supporting patients and families.
• Ability to assess psychosocial needs, develop appropriate interventions, and collaborate with multidisciplinary healthcare teams.
• Strong interpersonal, communication, organizational, documentation, and problem-solving skills.
• Ability to work effectively with patients and families from diverse socioeconomic, cultural, and clinical backgrounds.
• Ability to maintain patient confidentiality, exercise professional judgment, and carry out responsibilities under appropriate supervision.

Preferred Qualifications
• 1+ year of professional social work experience in a hospital, healthcare, behavioral health, or related clinical setting.
• Experience conducting psychosocial assessments, coordinating discharge plans, and facilitating transitions of care in an acute care hospital.
• Experience providing crisis intervention, grief and bereavement support, and counseling to patients and families with complex medical or psychosocial needs.
• Experience with pediatric, adolescent, adult, geriatric, or other specialty patient populations.
• Knowledge of Medicare, Medicaid, managed care, and healthcare coverage requirements relevant to discharge planning and access to services.
• Familiarity with federal and New York State healthcare regulations, mandated reporting requirements, and The Joint Commission standards.
• Experience collaborating with community organizations, protective services agencies, and post-acute care providers.
• Experience using electronic medical records (EMR/EHR) for clinical documentation and care coordination.
• Certified Case Manager (CCM) credential.