Care Coordinator SW PRN

About the Role

The Care Coordination Social Worker (CC SW) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as a key resource for patients and as a consultant to other care team members regarding patient's psychosocial and resource needs. In conjunction with the patient and physician, the CC SW will assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care. The role integrates and coordinates the patients' transitional care plan into their individualized discharge plans based on needs and resources available.

Responsibilities

• Provide psychosocial assessments for patients to include 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, etc.) and offer guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
• Serve as a specialist on issues related to psychosocial and discharge needs, end-of-life care planning, and resource needs.
• Provide resource information necessary to aid patient/families in decision-making, including support for end-of-life care.
• Partner and offer feedback to the RN Case Manager concerning complex social determinants of health issues, situational dynamics, and social needs.

Core Responsibilities and Essential Functions

Disposition Planning

• Implement discharge planning and provide resource information in a timely and efficient manner for patients.
• Identify and document barriers for timely disposition.
• Understand eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
• 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 make recommendations for 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 them to make autonomous healthcare decisions, keeping the patient and their wishes at the center of all discharge planning.
• Allow for any cultural or religious beliefs in providing service and continuity of care.
• Participate in the development of protocols, procedures, and performance improvement as indicated to optimize patient outcomes.

Assessment

• Based on preliminary screening of patients, initiate assessment of patients' psychosocial risk factors and availability of resources to assist upon discharge.
• Partner with PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
• Collaborate with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both 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 clear and concise.
• 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.

Professional Development and Initiative

• Complete all initial and ongoing professional competency assessments, required mandatory education, and population-specific education.
• Support departmental-based goals which contribute to the success of the organization.
• Serve as a preceptor and/or mentor for social work students (if appropriate).
• Perform other duties as assigned.
• Comply with all Wellstar Health System policies, standards of work, and code of conduct.

Requirements

• Bachelor's in Social Work or Master's in Social Work (preferred).
• Minimum 1 year of experience in healthcare in the acute care setting, related field, or skilled care environment, or community/educational internship in care coordination.
• Background in medical social work in an acute care setting (preferred).

Qualifications

• BLS - Basic Life Support or ARC-BLS - American Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor.
• LCSW - Licensed Clinical Social Worker GA or LCSW-P - Licensed Clinical Social Worker - Provisional (within 1 year).
• LMSW - Licensed Master Social Worker GA or LMSW-P - Licensed Master Social Worker - Provisional (within 1 year).

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 operate in a fast-paced environment.
• Strong assessment, interview, organizational, and problem-solving skills.
• Knowledge regarding local, state, and federal regulations required.
• Knowledge of community and state-wide resources and programs.
• Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

Schedule

Day shift (United States of America).