UnityPoint Health

Cross Continuum Social Worker MSW

Requisition ID
221 NE Glen Oak Ave
9010 Administration
Care Management- Ambulatory
Scheduled Hours/Shift
Days, Monday - Friday
Work Type (Portal Searching)
Full Time Benefits


As a member of the interdisciplinary team, contributes professional social work knowledge and skills in the provision of services that support patient and family access to health care and address psychosocial factors that influence a patient’s health.  


Patient Care 

  • Performs psychosocial assessment of the patient to identify priority needs, strengths, patient preferences and barriers to care.  
  • Provides crisis intervention and supportive counseling to patients/families to support their ability to cope with the impact of health conditions. 
  • Educates patient/family regarding Advanced Directives and facilitates/documents advanced care planning conversations with patients/surrogate decision makers including First Steps and IPOST/IPOLST. 
  • Maintains comprehensive knowledge of community resources and acts as a liaison to refer patients/families to health and social services, health insurance, public assistance and other resources to meet patient identified needs. 
  • Assists with planning for care transitions and collaborates with UPH, community services, and facilities to support patient safety and continuity of care.  
  • Completes PASRR or other screening tools when appropriate for transition to another care provider. 
  • Documents assessments, interventions, and referrals in the electronic health record according to documentation standards. 

Education and Advocacy 

  • Serves as a patient/family advocate in support of patient confidentiality, informed consent, patient autonomy, and self-determination. 
  • Assesses patient safety to identify possible abuse, neglect or other risks to safety. Collaborates with the care team to address safety issues and files DHS reports and/or guides others in the process as mandated. 
  • Provides information and support with guardianship and conservatorship issues.  
  • Supports culturally competent services and assists with arranging interpreter services as needed. 
  • Provides education to the patient/family regarding available services and supports and assists the patient to access those they are eligible for.  
  • Provides information and education to physician and other team members in understanding the psychosocial implications of illness and disease progression for the patient/family.  
  • Participates in mentoring new employees and/or supervising social work interns as requested. 

Care Coordination 

  • Provides expertise and plays a key role with the care team in establishing patient-centered goals of care and identifying psychosocial and behavioral strengths and barriers.  
  • Facilitates and/or participates in interdisciplinary team meetings to review and revise the patient plan of care. 
  • Facilitates patient/family meetings to enhance family support of the patient’s care. 
  • Collaborates with social workers and other professionals across the continuum and in the community to ensure continuity of care. 



  • Master’s degree in Social Work from an accredited school of social work.


  • Prefer one year clinical experience in health care.


  • Current licensure in good standing to practice social work at the Master’s level in the state where services are provided (LMSW).
  • Basic Life Support (BLS) certification.
  • Successfully complete Person Centered Care course within 6 months of hire.
  • Valid mandatory Reporter course completion by state(s) requirement.
  • Completion of First Steps (ACP) and IPOST/POLST training.
  • LISW (may be required in Illinois)


  • Knowledge of the social work process
  • Awareness and sensitivity to cultural diversity
  • Knowledge of the physiological elements of illness and impact on psychosocial functioning
  • Knowledge of the healthcare system and resources available to patients.
  • Strong interpersonal skills and ability to work as a collaborative team member
  • Knowledge of social determinants of Health
  • Strong verbal and written communication skills




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