St. John's Riverside Hospital is a leader in providing the highest quality, compassionate health care utilizing the latest, state-of-the-art medical technology. Serving the Westchester community from Yonkers to the river town communities of Hastings-on-Hudson, Ardsley, Dobbs Ferry and Irvington, St. John's Riverside has been and continues to be a unique and comprehensive network of medical professionals dedicated to a tradition of service that spans generations.
St. John’s has been an integral part of the community since the 1890's and its’ commitment to provide the community with the most advanced medical services available continues to be the hospitals’ vision, mission and value. St. John's Riverside Hospital built itself around an early foundation of nursing and community service. In 1894, the Cochran School of Nursing, the oldest hospital-based school of nursing in the metropolitan area, was founded, thus making the St. John's Nursing Staff more than just the backbone of the hospital, but the heart and soul. St. John’s dedicated nurses give superior attention to those who need it most with a strong emphasis on patient and family-focused nursing care.
St. John’s Riverside Hospital staff is committed to making life better for all patients. The hospital continues to elevate the services provided with the goal of increasing the quality of life for all who entrust St. John's Riverside Hospital to their care.
St. John’s Riverside Hospital is an equal opportunity employer. We maintain a policy of non-discrimination in providing equal employment to all qualified employees and candidates regardless of race, creed, color, national origin, sex, age, disability, marital status, or other legally protected classification in accordance with applicable federal, state, and local law.
Personalized care together with advanced technology is what it means to be Community Strong
The Social Worker will be responsible for providing patient centered, mental health, strengths-based care management services to ensure outreach, engagement, assessment, care planning development & implementation, coordination and monitoring of assigned patients. Through a collaborative effort with the patient’s care team, the Social Worker will coordinate and advocate for services that will promote optimal health outcomes and reduce the usage of the Emergency Department and inpatient hospital stays.
• Conduct program intakes upon patient’s entry into HIV primary care services. Complete Comprehensive Mental Health Assessments within 30 days of initial program intake.
This shall include but not be limited to:
- Program-specific Comprehensive Intake & Assessments packet
- SBIRT & PHQ9
- Social Determent of Health
• Develop and implement individualized Care Plans with each patient within 30 days of patient assignment. Care Plans must reflect the needs and desires of patient as indicated from the assessment process. Care Plans are to be an active and fluid document that must be reviewed and updated on a regular basis.
• Conduct mental health assessments with patients at least annually.
• Provide therapeutic individual sessions to patients living with HIV, in order to enhance their mental wellbeing and promote housing stability.
• Facilitate support groups designed to promote mental health.
• Ensure that patient’s confidential health care and personal information is always protected. Responsible to ensure that appropriate consent forms are signed and updated as required. Ensure that exchanges of information are only disclosed to those individuals to which the patient has consented to. Responsible for the safeguarding of electronic devices and passwords.
• Coordinate all needed and required services for patients, including but not limited to medical, substance use, mental health, and social support services. Work with the patient toward independence and improved self-management skills using evidence-based intervention including Motivational Interviewing, Trauma Informed Care, role playing, modeling, teach back. Accompany patients to appointments with service providers to ensure access to and understanding of services provided and required follow-up.
• Responsible for carrying an on-going caseload and provide overall care coordination of assigned patients. Ensure that case conference activities with the patient and their care team occurs on an on-going basis and that information, including the care plan, is shared and discussed with appropriate care team members. Ensure that appropriate program specific case conferencing documentation is completed.
• Responsible to document all intervention conducted with the patient or on their behalf in the appropriate program’s format (AIRS) accurately and error free utilizing the Problem/Intervention/Follow-up (PIF) format. Track all intervention on the program specific Patient Contact logs. Documentation is to be completed immediately following the intervention and program specific month monitoring data is to be submitted no later then the 5th of the following month.
• Independently travel between multiple off-site locations. Travel as required to community-based meetings, provider sites, patient’s home and any other site to assist the patient in meeting individual care plan goals.
• Responsible to actively participate in the Department’s Quality Improvement and Quality Assurance efforts as directed by their supervisor, including but not limited to participation on the Department’s Quality Improvement Committee and Patient Centered Medical Home.
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