Start the day excited to make a difference...end the day knowing you did. Come join our team.

Essential Functions & Responsibilities:

• Identifies and screens high-risk patients for care coordination.
• Coordinates care of patients with clinical partners; helps patients advance towards realistic and desirable outcomes.
• Organizes and expedites treatment plan of care activities.
• Assesses for long term and/or future patient care needs by identifying probable changes in level of independence or functional quality.
• Communicates activity status updates regarding treatment plan with clinical partners.
• Provides information and education on community resources to patient and their families.
• Identifies tentative discharge needs and develops a working discharge plan within the first 48 hours of admission.
• Develops, coordinates and communicates discharge plans with the patient, family members and care team and promotes communication and collaborative coordination of care amongst care providers. Documents assessment and overall discharge plan in medical record. Manages patient/family/physician expectations.
• Collaborates with leadership to appropriately address concerns related to delays in discharge, barriers to discharge and trends noted. Identifies financial barriers for a safe discharge and refers patients and families to appropriate agencies.
• Assures that key regulatory requirements are met. Documents key updates using appropriate software.
• Delivers appropriate regulatory letters to patients and families.
• Collects delay data for outcome and key performance indicators and documents accordingly. Provides post-discharge support as needed via telephonic follow up or face-to-face contact with patients for care coordination services.
• Provides intervention in cases of child/elder abuse/neglect and guardianship cases.
• Serves as a resource person related to treatment decisions surrounding end of life and Medical Power of Attorney.
• Facilitates meetings and comprehensive care planning with interdisciplinary team. Delegates work to support team members.
• Performs other duties as assigned.

Qualifications:

• Bachelor's or Master's degree in Social Work.
• A minimum of two years of experience in social work.
• Experience with computer technology, specifically experience with Windows based programs, e-mail, and Microsoft Word.

Preferred:

• Experience in a healthcare field.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.