Social Worker, MSW or LCSW Beverly Hills, CA

Evaluates and implements social service programs for patients with psycho/social issues focusing on seniors catastrophic and chronically ill patients.
Develops social service documentation tool/templates in EMR for Social Work consults family counseling and group sessions and IS reports for outcome measurements.
Performs triage for patients within corresponding team(s) and assists in coordinating patient care delivery including DPA/POSLT and documents pertinent information in the case management system.
Implements transitions of care between inpatient and continued outpatient follow up and vice versa.
Initiates team care conference to include patient family and care providers.
Evaluates daily caseload and assess achievement of long and short term goals; Modifies goals with providers and care team based upon patient outcomes.
Compiles and presents statistics and reports relating to patient outcomes and document findings in the patients EMR.
Follows up on communication to the referral source IE PCP family member case manager home health personnel community social worker Health Plan etc.
Acts as the social services liaison for the department particularly in the areas of: Advance Care Planning discussions Complex discharge planning Biopsychosocial assessments.
Refers patients to agencies that provides supportive services optimizing patients health plan benefits.
Assists in arranging community resources (i.e. meals on wheels transportation services adult day care and info-line) and in the long term planning for patients transitioning to institutional setting.
Provides alternatives for patients requiring specific services.
Acts as the liaison to Population Health department in regard to chronic disease state management programs.
Assists in the development and implementation of new policies and procedures for the department.
Participates in answering SW Direct Assist Line to respond to providers call for SW support with patients experiencing possible suicidal ideation (SI) crises.
Conducts outreach and interventions for patients who have identified possible SI in completing PHQ9 depression screening questionnaire (crisis support MH
care/resource linkage).
Participates in advance care planning initiatives.