Care Coordinator, Social Worker - master's degree required

Position Summary

This position will be discharging planning and treatment planning. We are looking for someone with some experience in the hospital and who is well versed in adults and children. The hospital has 285 beds and you will be assigned patients daily to care for. This is not a remote job and requires you to show up in persona and interface with our patients.

Responsibilities

Position Summary

Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services to include assessing patients' risk factors and the need for care coordination, clinical utilization management and preventative care services.

Essential Functions

• Takes the lead in ensuring the continuity and consistency of care, across the continuum (inpatient, emergency and ambulatory care / outpatient) to ensure integrated delivery across all settings to include the facilitation comprehensive discharge planning (in the hospital) and follow-up care (as an outpatient).
• Develops an effective working relationship with the Patient and Family Counselors / Social Workers and the UR nurses to engage the patient / family to collaborate, advocate and problem solve, to support and enhance their functional ability, while ensuring an appropriate and timely discharge plan.
• Daily monitoring of progress towards discharge plans and / or need to alter discharge plan due to change in patient condition / family needs with a priority placed on those patients at highest risk for complication / admission / readmission.
• Educates patients / families with chronic illness about evidence-based standards of care to include self-management strategies.
• Identifies support needs for patients and their families, develops action plan(s), and provides creative guidance in initiating and overcoming any self-management strategies.
• Educates patients and families about the health care system and facilitates relationship building between the various settings.
• Ensures patients have access to prescriptions, durable medical equipment (DME), and other services as identified.
• Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus and evaluating outcomes of treatment options to include tracking patient progress towards care plan goals and revising the care plan as indicated.
• Advocates for patients in order to optimize their health care needs including but not limited to : safety, physical, legal and financial well-being.
• Refers patients to education regarding the healthcare delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services, as appropriate.
• Works with available IT resources (i.e. Phytel, Crimson) to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines and the implementation of clinical decision

support tools, referral and test tracking, and preventive medicine reminders.

Qualifications

Education / Training

Master's degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required.

Licensure / Certification

Handle with Care (HWC) Certification required for Behavioral Health Unit.

Experience

Two (2) years of direct clinical experience with an emphasis on the population to be served in the assigned area. Successful completion of Master's level internship within the population to be served may substitute the two (2) years of experience.