Complex Care Coordinator SW KHC

3110 Kennestone Hospital, Inc.•Marietta, GA

About The Position

The SW Complex Care Coordinator assesses complex patient transitional care needs, coordinates care across the continuum, and works with patients and families to ensure care needs are met. The role serves as an expert resource for complex patients and situations, advising care team members on clinical, psychosocial, and resource needs. In partnership with patients and physicians, the coordinator assesses, coordinates, and implements timely, safe discharge plans to the next appropriate level of care. The coordinator provides comprehensive clinical and psychosocial assessments for complex patients, including those at high risk of readmission, high cost, long stays, or difficult placement. The position carries a caseload of selected complex patients and coordinates care with the patient care team. It contributes community resource expertise to interdisciplinary care, supports patients and families with psychosocial and multi-system issues, and advises on complex discharge needs, end-of-life planning, and resource needs. The coordinator also supports other care coordinators through consultation, mentoring, and precepting, and may facilitate hospital team meetings and help leaders negotiate agreements with community agencies and facilities.

Requirements

Bachelor's degree in Social Work; a Master's degree in Social Work is preferred.
BLS, ARC-BLS, or BLS-I certification.
Georgia LCSW or LMSW license.
At least 3 years of experience in healthcare in an acute care setting, related field, skilled care, or community environment.
At least 2 years of care coordination experience in an acute care setting.
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 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 throughout the continuum of care.

Nice To Haves

Master's degree in Social Work.
Accredited Case Manager (ACM) certification upon hire.
Certified Case Manager (CCM) certification upon hire.

Responsibilities

Implement timely and efficient discharge planning for complex patients and provide information about relevant resources.
Identify and document barriers to timely disposition.
Understand eligibility requirements for private and public local, state, and federal resources to support safe discharge transitions.
Respond to referrals for patient assistance from nurses, physicians, and the care team.
Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend an appropriate next level 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, keeping patient wishes central to discharge planning and supporting autonomous healthcare decisions.
Arrange and facilitate family meetings when needed, while accounting for cultural and religious beliefs in care continuity.
Assess psychosocial risk factors and available discharge resources based on preliminary patient screening.
Partner with the PAS, financial counselor, and/or utilization management nurse to assess insurance coverage requirements.
Collaborate with patients, families, physicians, and other care team members to support care progression and discharge plans.
Complete and document initial psychosocial and functional assessments in the medical record.
Maintain current, understandable, timely, and accurate documentation of progress notes, patient and family interactions, and services arranged or delivered in the Electronic Health Record; enter avoidable days when applicable.
Complete required initial and ongoing competency assessments and mandatory and population-specific education.
Support departmental goals and participate in developing protocols, procedures, and performance improvement activities.
Precept new hires and student interns as needed and mentor less senior care coordinators on challenging patient and family situations.
Serve as a specialist and consultant on complex psychosocial needs, discharge planning, end-of-life care, social determinants of health, financial, legal, situational, and other resource needs.
Provide patients and families with resource information to support decision-making, including end-of-life decisions.
Facilitate hospital team meetings when needed to reduce length of stay and resource consumption for complex patients.
Support leaders in negotiating agreements with community agencies and facilities.
Perform other assigned duties and comply with Wellstar Health System policies, standards of work, and code of conduct.