SOCIAL WORKER LMSW

Social Worker (LMSW) / Discharge Planner

At The Hamlet Rehabilitation and Healthcare Center at Nesconset, residents are treated to a complete spectrum of Rehab Services and Clinical / Nursing Care. Our specialized in-house programs include short-term subacute Rehab and long-term care, short-term post hospitalization and post acute care, as well as Adult Day Health Services .

The Hamlet Rehabilitation and Healthcare Center at Nesconset is in search of a capable, hardworking and talented Social Worker (SW) / Discharge Planner to join our ever growing team.

Job Summary

Provides, coordinates and facilitates patient discharge planning in collaboration with other health care professionals  Assist with organizing services across provider lines, between people, and systems to affect optimal patient outcomes, achieve continuity of care and reduce costs.

Essential Functions

• Promote the mission, vision, and values of the organization and home healthcare.
• Identifies patients for teaching, discharge, to assisted living facilities.
• Collaborates with physicians, caregivers, patient, family, other departmental team members, and payor to proactively develop and implement a safe and appropriate discharge plan.
• Participates in team meetings that foster interdepartmental collaboration with the patient and their family as deemed necessary, this includes multidisciplinary meetings and Utilization Review / Provides input in such meetings regarding utilization management and discharge planning.
• Applies utilization review criteria to assess continued stay, level of care, and readiness for discharge.
• Maintains working knowledge of Medicare, Medicaid and private insurance company coverage for referred products and services.
• Ensures that a quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the appropriate department; reports and identifies data that indicates potential areas for improvement of care and services provided within the system.
• Knowledgeable of patient’s financial status, diagnosis and discharge needs and documents these as an ongoing review.
• Maintains a current list of resources for referrals and refers to the appropriate inpatient, outpatient and community resources.
• Perform and complete follow up phone calls in a timely manner, provide referrals / data according to the patient’s needs, ensure patient visits PCP.
• Participate and communicate with the care team in management of the patient through the ACO program and manage PMI Center Dashboard.
• Maintain HMO Log and transmit to Corporate weekly.
• Hold all short term care plan meetings initial and subsequent.

Non-Essential Functions

Professional Requirements

Qualifications

Knowledge, Skills, and Abilities

Salary up to $75,000