Job Description

UPMC Your Care is seeking a Social Worker (MSW) with a passion for community-based care and a deep understanding of Allegheny County resources . This is a unique opportunity to be part of a growing department that is redefining how care is delivered in the community.

Purpose:
The Social Worker is responsible for providing complete psychosocial assessments, care coordination, crisis intervention, individual, family, group, bereavement and end of life counseling, and timely and appropriate discharge planning based on known or anticipated needs for UPMC Your Care UPMC Health Plan members. Collaborates and facilitates care with members’ primary care provider, UPMC Your Care Interdisciplinary Team, other departments, providers, community resources, and caregivers to achieve desired member outcomes throughout the continuum of care. Members are followed by face-to-face interactions in their community, including the hospital, providers’ offices, skilled nursing facility, home, or other health care facilities. 

Responsibilities:

• Demonstrate the ability to identify, assess, counsel, and effectively intervene with medically and psychosocially complex members with the ability to understand complex dynamics related to the clinical situation. Successfully utilize therapeutic counseling methods such as crisis intervention, psychosocial support, brief goal-directed therapy, CISM, and/or other appropriate therapeutic methods that may be appropriate to the clinical situation. Complete a psychosocial assessment that includes social, economic, cultural, age-related, and behavioral factors, history of child, elder, or domestic abuse, prior psychiatric or substance abuse treatment, family and social support systems, and all other available resources as appropriate to the clinical situation. Collaborate effectively with the UPMC Your Care interdisciplinary team, members, and families, and relevant community resources to develop and implement an individualized plan of care. Continue to monitor and evaluate the plan of care, options, and available services throughout the healthcare setting to effectively meet the member and family’s needs. Reassess the plan of care as appropriate and as status changes. Maintain extensive knowledge of federal, state, and local assistance programs and community resources that affect member needs.
• Demonstrates expertise in accessing social systems by providing resource-specific information to members and families, initiating contact with appropriate resources, and facilitating the member/family’s ability to accept referrals. Educate and advocate for members and families to enhance their ability to make informed decisions regarding medical care, discharge planning, advance directives, and end-of-life care, including actively participating in the guardianship process when appropriate. Demonstrate a knowledge of reimbursement systems, the ability to educate patients and families regarding payer requirements/coverage for post-acute care services, and the ability to effectively advocate on behalf of the patient to obtain authorizations for continued care as appropriate. Provides accurate, timely, and appropriate documentation of all social work interventions in the medical record per regulatory policies and procedures. Demonstrate appropriate professional practice, maintaining respect for confidentiality and freedom of choice as outlined by the Code of Ethics by the National Association of Social Workers, as well as the State Board of Social Workers, Marriage and Family Therapists, and Professional Counselors. Attends and participates in face-to-face conferences, team meetings, and other work-related meetings. Acts as a mentor to social work students and/or serves as a field instructor to MSW students.

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