Complex Coordinator Complex Case SW

Wellstar Health System • Roswell, GA

1d

About The Position

The SW Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available. Specific functions within this role include: Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan. Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team. Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics. Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life. Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs. Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentor other care coordinators in case reviews and discussion of difficult situations, to include, but not limited to patient legal status, court regulations, financial options, suicidal ideation, grief and bereavement, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios. May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient population. Supports leaders in negotiating agreements with community agencies and facilities. May have other duties assigned as it relates to hospital complex patient population

Requirements

• Bachelors Social Work or Masters Social Work-Preferred
• BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor
• LCSW - Lic Clinical Social Worker GA or LMSW - Lic Master Social Worker GA
• Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environments. Required and Minimum 2 years in care coordination in the acute care setting. Required
• Excellent written and verbal communication skill.
• Must possess maturity, self-confidence, objectivity, and positive attitude.
• Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment
• Strong assessment, interview, organizational and problem-solving skills.
• Knowledge regarding local, state and federal regulations required.
• Knowledge of community and state-wide resources and programs.
• Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

Nice To Haves

• ACM - Accredited Case Manager Upon Hire Preferred
• CCM - Certified Case Manager Upon Hire Preferred

Responsibilities

• Complex Disposition Planning
• Assessment
• Documentation
• Professional Development and Initiative
• Precepting/Mentoring
• Performs other duties as assigned
• Complies with all Wellstar Health System policies, standards of work, and code of conduct.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level