Care Coordinator, Social Worker - Pool Per Diem - Day - Corp

About the Role

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

Qualifications

Education/Training: Bachelor’s degree in Social Work, Psychology, Sociology, or other related field.

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

Experience: One (1) year of direct clinical experience with an emphasis on the population to be served in the assigned area or a completed internship in healthcare.

Responsibilities

• Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory/outpatient) to facilitate integrated delivery, including comprehensive discharge planning (in the hospital) and follow-up care (as an outpatient).
• Develops an effective working relationship with the Care Management Team to engage the patient/family, collaborate, advocate, and problem-solve to support and enhance their functional ability while ensuring an appropriate and timely discharge plan.
• Monitors daily progress toward discharge plans and/or the need to alter discharge plans due to changes in patient condition or family needs, prioritizing patients at highest risk for complications, admission, or readmission.
• Educates patients and families with chronic illness about evidence-based standards of care, including self-management strategies.
• Identifies support needs for patients and their families, develops action plans, and provides guidance in initiating and overcoming self-management challenges.
• Educates patients and families about the healthcare system and facilitates relationship-building between various care settings.
• Ensures patients have access to prescriptions, durable medical equipment (DME), and other identified services.
• Contributes to problem-solving within the team through communication, collaboration, data collection, consensus-building, and evaluating outcomes of treatment options, including tracking patient progress toward care plan goals and revising the care plan as needed.
• Advocates for patients to optimize their healthcare needs, including safety, physical, legal, and financial well-being.
• Refers patients to education regarding healthcare delivery and reimbursement systems, prescription drug programs, health and wellness programs, community agencies, housing options, and other services as appropriate.
• Uses IT resources (e.g., Allscripts Care Management, EMR) to facilitate registry reporting, maintain specified patient populations, improve disease outcome measures through evidence-based guidelines, and implement clinical decision support tools, referral and test tracking, and preventive medicine reminders.
• Participates in clinical outcome measurement, including identifying strategies that promote population health.
• Ensures patient safety by adhering to policies, procedures, and standards in the performance of job functions.
• Maintains reasonably regular, punctual attendance consistent with organizational policies and applicable federal, state, and local standards.
• Maintains compliance with all organizational policies and procedures.

Skills

• Excellent analytical and team-building skills, with the ability to prioritize and work independently.
• Knowledge and skills necessary to provide care appropriate to the age of patients served, including understanding principles of growth and development over the lifespan.
• Awareness of medical/legal issues, patient rights, and compliance with standards of regulatory and accrediting agencies.