Job Description
Duties & Responsibilities:
- Conduct comprehensive psychosocial assessments to identify patient and family needs, risks, and barriers to care.
- Develop, implement, and evaluate individualized plans of care in collaboration with patients, families, and interdisciplinary teams.
- Reassess patient needs and adjust care goals and interventions as necessary.
- Communicate clinical recommendations and ensure effective patient handoffs with the interdisciplinary team.
- Identify and address social, emotional, physical, and environmental factors affecting patient care and discharge planning.
- Provide support and resources for end-of-life decision-making and bereavement needs.
- Support families dealing with complex dynamics and help resolve barriers to care and discharge.
- Manage crisis situations, de-escalate conflicts, and redirect challenging behaviors when appropriate.
- Assist families with legally complex cases and connect them with appropriate community resources.
- Maintain patient privacy and confidentiality in accordance with applicable requirements.
- Ensure timely and accurate documentation in the medical record.
Required Skills
- Ability to conduct thorough psychosocial assessments and develop, implement, and evaluate care plans.
- Understanding of the psychosocial needs of the assigned patient population.
- Experience coordinating community resources and supporting patients and families.
- Ability to manage crisis situations and complex psychosocial needs.
- Experience handling grief, bereavement, and end-of-life situations.
- Strong initiative, critical thinking, judgment, and problem-solving skills.
- Excellent listening, interpersonal, and communication skills.
Preferred Experience:
- Hospital experience.
- Behavioral health experience.