Care Transitions Social Worker

Company: Bryan Health
Location: Lincoln
Posted on: May 19, 2025

Job Description:

Summary

GENERAL SUMMARY:




Responsible for collaborating with health care team members to identify and plan for the complex and problematic psychosocial needs of the patient and family. Assists patients and families in adjusting to the demands of chronic health care needs across the continuum. Serves as a resource to the inter-disciplinary team. Provides support and case consultation to other case management team members when complex issues arise.




PRINCIPAL JOB FUNCTIONS:




1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Completes case management assessments; determines priorities for case management intervention and differential treatment needs of patients and families; documents assessment, plans and interventions based upon departmental standards.

3. *Utilizes knowledge of high-risk indicators to identify all forms of family violence; understands impact of different types of chronic illness on the patient and family.

4. *Provides supportive counseling to patients and families to enhance coping mechanisms.

5. Provides crisis intervention services to patients, families and staff; assists patients, families and staff in problem solving and conflict resolution.

6. *Serves as a resource to the inter-disciplinary team and Care Management Discharge Specialists in meeting complex needs of patients and families throughout the process of discharge planning.

7. *Partners with Care Management Discharge Planning staff to assist in identification and resolution of complex and problematic discharge planning issues.

8. Assists patients/families in understanding, accepting and following medical recommendations.

9. Facilitates communication with patients/families from a wide variety of developmental and social/cultural backgrounds; conveys an attitude of acceptance, sensitivity and caring.

10. *Initiates communication with peers about clinical practice issues.

11. Maintains good working relationships with a variety of community service agencies.

12. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

13. Participates in meetings, committees and department projects as assigned.

14. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk *. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.




REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:




1. Knowledge of crisis intervention and problem solving methods.

2. Knowledge of principles and practices of social work and supportive counseling techniques.

3. Knowledge of the impact of chronic illness on patient/family and intervention strategies.

4. Knowledge of dynamics involved in all types of family violence, high-risk indicators, legal responsibility and process for reporting.

5. Knowledge of computer hardware equipment and software applications relevant to work functions.

6. Ability to complete psychosocial assessments according to department procedure.

7. Ability to communicate effectively both verbally and in writing.

8. Ability to perform crucial conversations with desired outcomes.

9. Ability to work in a fast-paced environment related to changing patient needs including working with patients with acute, chronic and complex disease processes and those who are dying.

10. Ability to establish and maintain effective working relationships with all levels of personnel, medical staff, volunteer and ancillary departments including diverse patient populations.

11. Ability to plan, organize and implement social work services to patients with needs common to area of assigned responsibility.

12. Ability to problem solve and engage independent critical thinking skills.

13. Ability to maintain confidentiality relevant to sensitive information.

14. Ability to prioritize work demands and work with minimal supervision.

15. Ability to maintain regular and punctual attendance.




EDUCATION AND EXPERIENCE:




Masters degree in Social Work (MSW) from a School of Social Work OR Masters degree in Counseling or related field required. Current certification as a Licensed Mental Health Practitioner (LMHP) by the State of Nebraska preferred. Prior case management experience desired.




OTHER CREDENTIALS / CERTIFICATIONS:




None
















PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)




(DOT) Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.




Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.

Keywords: Bryan Health, Grand Island , Care Transitions Social Worker, Healthcare , Lincoln, Nebraska