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Licensed Clinical Social Worker, Per diem

Manhattan, New York Social Services
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Job ID R011001

Provides targeted social work services to patients at high risk for rehospitalization during a transitional care episode in the Transitional Care Program. Functions as part of a nurse practitioner-led team providing services to this population. Works under general supervision.



What You Will Do

  • Collaborates with the transitional care team to perform interventions during post hospital discharge period aimed at reducing preventable hospitalizations.
  • Makes home visits to patients in the program after hospital discharge with defined social service needs and develops a plan for the transitional care episode in collaboration with the program team.
  • Conducts weekly or more frequent phone visits to the patient and family/caregiver with defined social service needs. Telephone monitoring is for the purpose of patient assessment, monitoring and self management education and support.
  • Establishes the social work component of the client/family plan of care based on goals mutually acceptable to the client, family and significant others. Makes referrals to other community services, as necessary.
  • Travels to patients’ homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct service to the client.
  • Provides psychosocial work services to client and/or family, including short-term individual counseling, community resource planning, crisis intervention and assistance in obtaining entitlements and community services.
  • Assesses clients and /or family psychosocial status, social work needs and living conditions utilizing professional knowledge, observation skills and interviewing skills.
  • Assesses the need for ongoing psychiatric care and assures the transition to a primary psychiatric provider.
  • Initiates and maintains verbal and written communication, including the preparation of clinical and progress notes, to ensure optimal quality client care and continuity.
  • Maintains productivity sufficient to meet program goals.
  • Assists team members in understanding the significant social and emotional factors related to the client’s health problems.
  • Uses an electronic medical record to document appropriate social work interventions and to allow reporting and outcome evaluation measures.
  • Participates in the development of a treatment plan and revises the goals as needed. Coordinates approaches to client and/or family care with other team members.
  • Consults with and educates the client and family regarding the treatment plan, self-care techniques and prevention strategies.
  • Acts as a program representative at institutional and community programs and functions. Provides information as needed about the program and services. Provides continuous feedback on the social work clinical model and participates in program modification efforts.
  • Participates in discharge planning from the Transitional Care Program.
  • Assumes responsibility for continued professional growth, such as in-service programs.
  • Depending on the site of provision of care, transports and utilizes designated/supplied carrying case weighing up to 30 lbs. (as needed) to and from patient homes/care facilities, program offices and other locations.
  • Participates in regular case conferences that result in refinement of the social work services delivered in order to meet program goals.
  • Participates in the orientation of new Licensed Clinical Social Workers and other program staff and acts a preceptor for new staff.
  • Participates in special projects and performs other duties as assigned.


Licenses and Certifications:

  • Current registration to practice as a Licensed Clinical Social Worker (LCSW) in New York State Required
  • Valid driver's license as determined by operational/regional needs may be Required


  • Master's Degree in Social Work required

Work Experience:

  • Minimum of four years social work experience as a direct clinical service provider and/or discharge planner in a health care setting required
  • Experience with chronically ill patients preferred
  • Bilingual skills as determined by operational needs may be required

About Us

VNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 125 years, our commitment to health and well-being is what drives us—we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.

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  • Social Services, Manhattan, New York, United StatesRemove

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