The Care Coordinator MSW plays a crucial role in supporting patient populations with chronic illnesses and multiple co-morbidities. This position involves collaborating with a multidisciplinary team, including Continuum Care Managers, Case Managers, Care Navigators, Physicians, Nursing, and PCP. The coordinator adheres to established care management standards, utilizing evidence-based protocols and cost-effective, patient-focused interventions. Responsibilities include coordinating care between various departments, medical clinics, and community outreach programs to ensure patient safety, smooth transitions of care, and effective management of utilization and total cost of care. The role applies social work methods for assessment, education, collaboration, and resource coordination to help patients achieve optimal functional health status and improve their quality of life. Support services extend to Endeavor patients and value-based contract members, including care coordination and counseling. The position also involves intervening in critical situations such as child abuse/neglect, domestic violence, guardianship, mental health placement, substance abuse, advance directives, adult/elderly/disabled abuse and neglect, and sexual assault. Ensuring safe patient care while adhering to policies, procedures, standards, and budgetary specifications is paramount. The role also includes initiating and facilitating Advance Care Planning and goals of care discussions, considering the developmental stages of patients and involving families in the plan of care.
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Job Type
Full-time
Career Level
Mid Level