Care Coordination Sr SW

About the role

At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Responsibilities

• Assess transitional care needs, coordinate care across the continuum, and engage with patient and family to assure care needs are met.
• Serve as an expert resource for complex patient situations and a consultant to other care team members regarding patient psychosocial and resource needs.
• Assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care in conjunction with the patient and physician.
• Integrate and coordinate the patient’s transitional care plan into individualized discharge plans based on needs and available resources.
• Provide psychosocial assessments for patients, including timely and appropriate planning to advance the discharge plan.
• Assist in relaying information about community-based service offerings (e.g., indigent care referrals and assistance, specialty care or post-acute placements, elder assistance) and guide patients/families through multi-system factors affecting psychosocial dynamics.
• Specialize in issues related to psychosocial and discharge needs, end-of-life care planning, and resource needs.
• Provide resource information to aid patient/family decision-making, including support for end-of-life care.
• Partner with RN Care Coordinators to address complex social determinants of health, situational dynamics, and social needs.
• Participate in orientation and precepting of new social work hires as needed.
• Mentor other social workers in case reviews and discussions of difficult situations, including assessing suicidal ideation, bereavement risk, social determinants of health, cultural or language barriers, and abuse cases (children and adults).

Core Responsibilities And Essential Functions

Complex Disposition Planning

• Implement discharge planning and provide resource information in a timely and efficient manner for complex patients.
• Identify and document barriers for timely disposition.
• Understand eligibility processes and criteria for private and public local, state, and federal resources to assist in planning a safe and appropriate discharge transition.
• Respond to referrals for patient assistance from RN Care Coordinators, physicians, and the care team.
• Participate in Interdisciplinary Rounds with the patient’s care team to confirm estimated date of discharge and recommend the best level of care transition at discharge.
• Initiate/facilitate post-acute referrals through departmental processes for timely transition to the next level of care.
• Provide financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.
• Advocate and partner with the patient and family to empower autonomous healthcare decision-making, keeping the patient’s wishes at the center of discharge planning.
• Respect cultural or religious beliefs in providing service and continuity of care.

Assessment

• Initiate assessment of patients’ psychosocial risk factors and availability of resources to assist upon discharge based on preliminary screening.
• Partner with PAS, financial counselor, and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence.
• Collaborate with the patient and family, along with physicians and other care team members, to establish and support the patient’s care progression and discharge plans.

Documentation

• Complete and document initial psychosocial/functional assessment in the medical record.
• Ensure all records are up-to-date and documentation is understandable.
• Ensure timely and accurate documentation of progress notes and interactions with patient/family.
• Account for and indicate all services arranged/delivered in the Electronic Health Record.
• Track avoidable days and report trends that lead to undesired outcomes.

Precepting/Mentoring

• Assist leadership with precepting new hires when needed.
• Mentor new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.
• Serve as a preceptor and/or mentor for student interns.

Professional Development and Initiative

• Complete all initial and ongoing professional competency assessments and required mandatory education.
• Support departmental-based goals that contribute to the success of the organization.
• Participate in the development of protocols, procedures, and performance improvement to optimize patient outcomes.

Requirements

• Bachelor of Social Work or Master of Social Work (preferred).
• Minimum 2 years of experience in healthcare in the acute care setting, related field, skilled care environment, or community.
• A background in medical social work in an acute care setting is highly preferred.

Licenses and Certifications

• BLS (Basic Life Support) or ARC-BLS (American Red Cross Basic Life Support) or BLS-I (Basic Life Support – Instructor).
• LMSW (Licensed Master Social Worker) in Georgia or LCSW (Licensed Clinical Social Worker) in Georgia.
• LMSW in the State of Georgia (can be waived if holding LCSW in the State of Georgia).
• ACM or CCM (upon hire preferred).

Skills

• Excellent written and verbal communication skills.
• Maturity, self-confidence, objectivity, and positive attitude.
• Self-directed with the ability to function well under stress, handle change, and work in a fast-paced environment.
• Strong assessment, interview, organizational, and problem-solving skills.
• Knowledge of local, state, and federal regulations.
• Knowledge of community and state-wide resources and programs.
• Ability to work collaboratively with physicians, care team members, and patients/families to assist through the continuum of care.