Care Coordinator PRN Level 1 KHC
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 help ensure their needs are met. The role serves as a resource for patients and a consultant to care team members regarding psychosocial and resource needs. In partnership with patients and physicians, the CC SW assesses, coordinates, and implements timely, safe discharge plans to the next appropriate level of care, integrating transitional care plans into individualized discharge plans based on patient needs and available resources. The CC SW provides psychosocial assessments and timely planning to advance discharge, explains community-based services and referrals, and guides patients and families through factors affecting their psychosocial circumstances. The role provides expertise on psychosocial and discharge needs, end-of-life planning, and resource needs, and partners with the RN Case Manager on complex social determinants of health and situational needs. Other duties may be assigned.
Requirements
- Bachelor of Social Work; a Master of Social Work is preferred.
- 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 care-coordination internship.
- Required certification: BLS, ARC-BLS, or BLS-I.
- Required licensure: Georgia LCSW or provisional LCSW within one year, and Georgia LMSW or provisional LMSW within one year.
- Excellent written and verbal communication skills.
- Maturity, self-confidence, objectivity, and a positive attitude.
- Ability to work independently, handle stress and change, and function in a fast-paced environment.
- Strong assessment, interviewing, organizational, and problem-solving skills.
- Knowledge of 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
- Master of Social Work.
- Background in medical social work in an acute-care setting.
Responsibilities
- Implement discharge planning and provide timely resource information to patients.
- Identify and document barriers to timely disposition.
- Apply eligibility processes and criteria for private and public local, state, and federal resources when planning safe, appropriate discharge transitions.
- Respond to patient-assistance referrals from RN Care Coordinators, physicians, and the care team.
- Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend appropriate levels of care.
- Initiate and facilitate post-acute referrals through departmental processes.
- Assess financial needs for patients requiring assistance with follow-up care across the continuum.
- Advocate for and partner with patients and families to support autonomous healthcare decisions and patient preferences in discharge planning.
- Respect cultural and religious beliefs in providing service and continuity of care.
- Participate in developing protocols, procedures, and performance improvement efforts as indicated.
- Assess psychosocial risk factors and available discharge resources based on preliminary patient screening.
- Partner with PAS, financial counselors, and/or UM nurses to assess insurance coverage requirements for all payers.
- 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.
- Keep records current and documentation clear and concise; document progress notes and patient/family interactions accurately and promptly.
- Record all services arranged or delivered in the Electronic Health Record.
- Track avoidable days and report trends associated with undesired outcomes.
- Complete initial and ongoing competency assessments and required mandatory and population-specific education.
- Support departmental goals that contribute to organizational success.
- Serve as a preceptor and/or mentor for social work students, if appropriate.
- Comply with Wellstar Health System policies, standards of work, and code of conduct.
- Perform other duties as assigned.
