In support of patient progression practice, create optimal outcomes for the patient and the family by managing complex psychosocial and economic barriers to patient progression. Through advanced practice skills mobilizes resources to reduce risk to the patient and families secondary to social determinant based needs and challenges. Provides patient support with cultural humility to ensure that interventions by the care team are rendered respectfully to diverse populations.

• Identifies patient and/or families requiring coordination of continuing care or community support members of the care team.  Reviews medical records, attends rounds, and responds to patient’s needs.  Applies knowledge based on professional experience.
• Understands and adheres to the practice standards consistent with patient progression and its contribution to the strategic plan.
• Works collaboratively with the RN Case Manager and the treatment team members to develop and coordinate a safe, timely and appropriate discharge plan across the care continuum, addressing psychosocial barriers, with multiple resource dependent level of care options that comply with regulations and laws regarding patient/family participation with planning and choice.
• Coordinates post-acute discharges for complex patients in collaboration with Care Management Discharge Manager.
• Identifies the need for and conducts in a timely fashion patient family meetings that result in decisions regarding advance directives, comfort measures, power of attorney, guardianship, conservatorship, and goals of care.
• Completes initial psychosocial screen of patients and families as indicated. Serves as the lead in addressing psychosocial needs of patients relating to social determinants of health, barriers to equal access to healthcare, and patient progression; this includes obtaining charity and financial resources, legal guardianship, adoptions, psychiatric referrals, and competency determination.  
• Provides referrals for post-acute transitions to/for LTACH, SNF, IRF, LTC , HH and DME.
• Conducts practice consistent with social work ethical principles, adhering to standards set forth from NASW and ACMA Case Management practice standards.
• Identifies the need for and conducts family meetings that result in comfort, treatment and discharge planning decisions, and other important outcomes.
• Leads Care Coordination/Interdisciplinary Rounds and documents.
• Advocates for patient care and timely discharge plan.
• Works with people and agencies in the community to improve responsiveness, capabilities, alignment, and evaluation of services to patients and families.
• Utilizes age-appropriate assessments and interventions during all client contacts.
• Collaborate with Risk Management, Patient Relations, Utilization Management, the Ethics Committee and other departments for ethical issues and utilizes the NASW Code of Ethics in appropriate decision-making.
• Demonstrates flexibility and partnership with the care management team members to ensure the needs of patients are met.
• Assists patients and families in understanding their illness and treatments options, consequences to various treatments or refusal of treatment, and necessary levels of care, including acute, subacute, and community services.
• Assists patients and families in communicating with treatment team
• Educates hospital staff on patient psychosocial needs.
• In addition to the above job responsibilities, other duties may be assigned.

MINIMUM REQUIREMENTS
Education: Master's of Social Work required.

Experience: One year of experience performing discharge planning in an acute or subacute setting.
Licensure: LMSW/LCSW preferred. ACMA certification preferred.

PHYSICAL DEMANDS
Job requires standing for prolonged periods, frequently walking, bending/stooping.  Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20-50 lbs.  May be exposed to chemicals, blood/body fluids, and infectious disease.

Position Compensation Range: $54,558.40 - $87,297.60 Annual

Benefits

• Comprehensive Benefits Package: Medical, Dental, and Vision Insurance

• Paid Time Off, Long-term and Short-term Disability, Retirement Savings

• Health Saving Plans, and Flexible Spending Accounts

• Certification and education support

• Generous Paid Time Off

UVA Health is a world-class Magnet Recognized academic medical center and health system with a level 1 trauma center. 2023-2024 U.S. News & World Report “Best Hospitals” guide rates UVA Health University Medical Center as “High Performing” in 5 adult specialties and 14 conditions/procedures. We are one of 70 National Cancer Institute designated cancer centers. UVA Health Children’s is named by 2023-2024 U.S. News & World Report as the best children's hospital in Virginia with 9 specialties ranked among the best in the nation. Our footprint also encompasses 3 community hospitals and an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, Northern Virginia, and beyond.