Responsibilities:

• Conducts comprehensive psychosocial assessments, including evaluation of mental health, coping, family systems, cultural factors, and social determinants of health 

• Provides clinical social interventions, counseling, and crisis support to patients and families coping with serious illness, end-of-life concerns, and grief 

• Serves as an integral member of the interdisciplinary palliative care team, contributing to treatment planning and goal-of-care discussions 

• Facilitates and/or leads family meetings to address complex family dynamics, clarify goals of care, and support shared decision-making 

• Provides caregiver assessments, education, and ongoing support to strengthen the family system 

• Assist patients and families with advance care planning, including healthcare directives and identification of surrogate decision makers 

• Coordinates transitions of care across inpatient, outpatient, and community settings 

• Demonstrates strong knowledge of community and healthcare resources, including mental health services, grief support, housing, substance use treatment, long-term care, home care services, equipment coordination, and home safety 

• Utilizes the Clinical Practice Guidelines for Quality Palliative Care and organizational standards to guide practice 

• Maintains timely, accurate, and compliant documentation in the electronic medical record 

• Provides consultation and support to medical and nursing staff regarding psychosocial and family dynamics 

• Participates in quality improvement, program development, and team education as appropriate 

• Identify program and community need to drive strategic program development, resulting in optimized workflows, improved collaboration and successful execution of key initiatives 

• Familiarity with medical terminology and documentation or a proven ability to learn new systems quickly