Care Coordinator SW FT Days

Wellstar Health System•Austell, GA

About The Position

The Care Coordination Social Worker (CC SW) assesses patients’ transitional care needs, coordinates care across the continuum, and engages patients and families to ensure their needs are addressed. The role serves as a resource for patients and a consultant to care team members regarding psychosocial and resource needs. In partnership with the patient and physician, the social worker assesses, coordinates, and implements a timely, safe discharge plan to the appropriate next level of care, integrating the transitional care plan into individualized discharge planning based on patient needs and available resources. The CC SW conducts psychosocial assessments and supports timely discharge planning; shares information about community services, referrals, and post-acute placements; and advises patients and families about psychosocial, resource, and end-of-life care needs. The social worker partners with the RN Case Manager on complex social determinants of health, situational dynamics, and social needs. Other duties may be assigned.

Requirements

At least one year of experience in healthcare in an acute care setting, a related field, a skilled care environment, or a community or educational internship in care coordination.
BLS, American Red Cross BLS, or BLS Instructor certification is required upon hire.
Excellent written and verbal communication skills.
Maturity, self-confidence, objectivity, and a positive attitude.
Ability to work independently, function under stress, handle change, and work in a fast-paced environment.
Strong assessment, interviewing, organizational, and problem-solving skills.
Knowledge of applicable local, state, and federal regulations.
Knowledge of community and statewide resources and programs.
Ability to collaborate with physicians, care team members, patients, and families across the continuum of care.

Nice To Haves

Bachelor’s or master’s degree in social work (master’s preferred).
Background in medical social work in an acute care setting.

Responsibilities

Implement discharge planning and provide timely, efficient resource information to patients.
Identify and document barriers to timely disposition and understand eligibility criteria for public and private resources that support safe transitions.
Respond to patient assistance referrals from RN Care Coordinators, physicians, and other care team members.
Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend an appropriate level of care at discharge.
Initiate and facilitate post-acute referrals through departmental processes.
Assess financial needs for patients requiring assistance with follow-up care.
Partner with patients and families and advocate for autonomous health care decisions that center on patient preferences and wishes.
Respect cultural and religious beliefs while supporting service and continuity of care.
Participate in development of protocols, procedures, and performance improvement activities as indicated.
Assess psychosocial risk factors and available discharge resources based on preliminary patient screening.
Work with the PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements.
Collaborate with patients, families, physicians, and care team members to support care progression and discharge plans.
Complete and document initial psychosocial and functional assessments in the medical record.
Maintain current records and clear, concise, timely, and accurate progress notes and documentation of patient and family interactions.
Record services arranged or delivered in the Electronic Health Record.
Track avoidable days and report trends associated with undesired outcomes.
Complete required initial and ongoing competency assessments and mandatory and population-specific education.
Support departmental goals and, when appropriate, serve as a preceptor or mentor for social work students.
Perform other assigned duties and comply with Wellstar Health System policies, standards of work, and code of conduct.