Social Worker - Care Coordinator

SUMMARY :

Partners with a multi-disciplinary team to coordinate a plan of care utilizing expertise in counseling, crisis intervention and medical-legal issues, to ensure optimization of health outcomes for patients and their families.

ESSENTIAL FUNCTIONS :

• Collaborates and communicates with multidisciplinary teams in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation to assesses, documents, and addresses psychosocial, cultural, emotional, and economic needs of patients and families during the hospitalization and discharge planning process.
• Assesses, creates, implements evaluates, and modifies timely discharge plans.
• Assesses, intervenes, and acts as a resource in medical-legal situations for patients and families.
• Requests assistance from RN Case Manager to enter nursing orders to ensure their assigned patient caseload discharge planning and transitional care needs are met.
• Assists patients and families in making difficult decisions, while honoring their preferences and values, in order to move the discharge plan forward.
• Collaborates with patients, family / caregiver, nursing, physician(s), and other members of the multidisciplinary team, creating consensus around issues of discharge planning.
• Ensures documentation in the electronic medical record is entered timely, is clear, complete, concise, and organized.
• Monitors clinically high risk and complicated cases and institutes necessary actions to promote quality care and appropriate integration with timely escalation as appropriate.
• Acknowledges and completes case management consults in a timely manner and identifies patients that meet the criteria for case management.
• Coordinates cases between health care providers and payors.
• Facilitation of precertification and payor authorization processes for medication.
• Facilitates the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and transition of care.
• Facilitates coordination between multidisciplinary team and patient / family / caregiver for care conferences when indicated.
• Develops treatment plan and discusses proposed course of treatment with patient’s attending physician, patient, family / caregiver, and other members of the multidisciplinary team.
• Ensures patient / family / caregiver / staff concerns are appropriately resolved in a timely manner.
• Identifies populations and patients at risk for re-admissions, establishes goals with patients and families, coordinates specific focused discharge interventions and services, makes contact with community partners for continuity of care.
• Works with clients and multidisciplinary team to identify discrepancies and barriers to health, wellness, and independence towards health equity.
• Improves understanding of access points for medical care resulting in decreased use of emergency resources, decreased hospital admission, re-admission, and unnecessary expenditures.
• Analyzes current operations, policies, systems, procedures, and develops and implements necessary and innovative changes.
• Exhibits excellence in customer service through appropriate attitude and interaction with all patients, visitors and staff.
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
• Assists with program planning, development, and evaluation.
• Adheres to TMC organizational and department-specific safety, confidentiality, values policies and standards.
• Collaborates with the multidisciplinary team, outpatient care team, and community partners as needed, to assist with length of stay, patient throughput initiatives and creatively resolve issues that could prevent safe and timely patient discharges.
• Ensures that all elements critical to the plan of care have been communicated to the patient / family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION : Master's in Social Work (MSW) or equivalent required (Master of Science in Social Administration (MSSA).

EXPERIENCE : One (1) year of related social work experience.

LICENSURE OR CERTIFICATION : HeartSaver First Aid CPR Certification or Basic Life Support (BLS) Certification.

KNOWLEDGE, SKILLS AND ABILITIES :