Social Worker- Housing Coordinator (Full Time, Day)

Location: ElderOne Hudson

About the Role

As a Social Worker, you play an important and trusted role in the lives of patients and their family. You are an integral part of their care and recovery.

Schedule

Monday through Friday, 8:00 AM to 4:30 PM

Attributes

• One (1) year of experience in a healthcare setting preferred
• Compassionate, warm and patient focused
• Exceptional documentation and planning skills
• Excellent communication and interpersonal skills

Responsibilities

• Determine patient needs through rounds, chart review, patient/family interviews, and team conferences
• Coordinate multidisciplinary and agency case conferences
• Work with care managers to advocate for patient/family to obtain approval for insurance coverage
• Manage referrals related to patients at risk and determine appropriate intervention strategies; document as implemented
• Ensure inappropriate referrals are channeled correctly and documented
• Coordinate assessments and develop care plans in accordance with accepted social work policy
• Implement plan of intervention preparatory to discharge or initiate continued care plan
• Review track board census or documentation to identify high-risk patients not referred
• Document social work intervention
• Assess patient needs and determine mode of intervention, including age-specific knowledge
• Interview patients and/or families and record psychosocial assessments
• Evaluate patients for the appropriate level of care when indicated
• Involve patient/family in the treatment planning process
• Execute mutually agreeable discharge/continued care plans
• Notify involved parties concerning discharge within 24 hours of receipt of discharge authorization
• Request needed paperwork from nursing, doctors, or other disciplines
• Arrange for patient transportation where needed in accordance with hospital procedure
• Act as liaison with the community and as a referral source

ElderONE Housing Coordination Responsibilities

• Eliminate wasted bed days in the hospital and skilled nursing facility due to housing barriers
• Build effective relationships to create housing options for ElderONE that vary in length of stay (short-term, long-term, permanent) and services provided
• Coordinate with interdisciplinary teams, discharge planners, and other RRH and non-RRH partners to ensure well-coordinated and timely discharges/transitions into housing
• Assist participants with all aspects of establishing housing (tours, documentation, paperwork, finances including rent, deposits, rep payee if needed)
• Monitor participants at risk for homelessness and create proactive mitigation plans to prevent unnecessary use of skilled nursing or higher levels of care
• Work with contracted and non-contracted skilled nursing facilities to provide housing options for patients who no longer desire a skilled nursing facility

Requirements

• For those hired on or before December 31, 2023: Bachelor’s Degree in Social Work or related degree
• For those hired on or after January 1, 2024: Bachelor’s Degree in Social Work
• Minimum of a Bachelor’s degree in social work; OR minimum of a Bachelor’s degree in a human-services related major (sociology, gerontology, psychology, rehabilitation counseling, or special education) AND one year in a healthcare setting as a supervised social worker working directly with individuals
• New graduates: Official transcript from an accredited school or letter from the school’s registrar’s office confirming program completion will be accepted upon graduation. Primary source education verification required within 90 days of start date.

Physical Requirements

• Sedentary work: Exerting up to 10 pounds of force occasionally. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods.

Pay

Pay Range: $25.50 - $35.00 per hour