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Transitions Social Worker

Transitions Social Worker
Job Ref: 16995
Category: Social Work
Location:
Emerson Hospital, Baker Ave Facility, 310 Baker Ave, Concord, MA
Department: PHO Care Management
Schedule: Full Time
Shift: Day shift
Hours: 8:00am-4:30pm
Job Summary:
The Care Transitions Social Worker (CTSW) supports PHO rising risk patients and other patients as referred by the Care Management Department and physicians during their transition from Emerson Hospital back to the community by assessing needs and proactively employing strategies to improve patient wellbeing. Using motivational interviewing techniques, the CTSW will identify sources of motivation for patients, guide creation of improvement goals, and support patients in reaching those goals. The CTSW will also establish long-term care plans for patients, providing warm-handoffs to the PCP and specialty practice physicians and/or social work/case management team in order to ensure patients have ongoing support beyond the period of transitional support. In addition, the CTSW will lead conversation on Goals of Care where appropriate, and assist patients with understanding their wishes.
Education:
€ Master's Degree in Social Work with LICSW preferred.
Experience:
€ Minimum of 2 years' experience working with elders and families required.
€ Knowledge of community resources and support services
€ Familiarity with MS Office Suite including Word and Outlook
Licensure and/or Certification:
? Valid driver's license and reliable vehicle
Skills:
€ Ability to use motivational interviewing to assist patients with defining goals
€ Excellent customer service skills
€ Must be able to demonstrate a positive image of Emerson Hospital as a caring and concerned organization at all times
€ Ability to maintain confidential information.
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Company Description:

Since 1911, our communities have looked to us to provide the most sophisticated, high-quality care available, close to home.


Today, Emerson has grown to become a regional health system serving over 300,000 individuals in 25 communities in our area. And while much has changed, our commitment has remained the same: to provide advanced care in an atmosphere of warmth and compassion. It's why we continually invest in new technologies and treatments. And it's why we invest so heavily in our people - in their education, their growth, their futures.




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