Continuing Care Coordinator (Social Work)
About The Position
St. John's Riverside Hospital is hiring a Continuing Care Coordinator to assess patients’ psychosocial and discharge-planning needs and coordinate appropriate services. The coordinator assesses assigned inpatients—including Intensive Care Unit patients—within three days of admission and manages their discharge plans until they transfer to another level of care. Through ongoing assessment and collaboration, the coordinator addresses patients’ medical, social, financial, and psychological status, reviews cases for quality-of-care and utilization-management issues, and supports a comprehensive discharge plan. The role works with nurses, physicians, case managers, and other members of the healthcare team to ensure appropriate resource use and length of stay. The position reports to the Director of Case Management.
Requirements
- Master’s degree in social work required.
- Hospital experience required.
- Ability to read, write, speak, and understand English.
- Professional communication and rapport with physicians, patients, family members and visitors, peers, and supervisors.
- Sensitivity and compassion.
- Knowledge of community services and health, welfare, and social agencies.
- Flexibility and creativity.
- Ability to function well under pressure.
- Good leadership ability and judgment.
- Good mental and physical health.
- Education in the use of a particulate respirator (mask).
Nice To Haves
- LMSW or LCSW preferred.
- New York State Screen Certification preferred.
- Ability to communicate in Spanish or another community-dominant language is desirable.
Responsibilities
- Assess assigned patients’ medical, social, financial, and psychological status within three days of admission.
- Screen patients for continuing-care needs, including emotional support, community resources, home care, rehabilitation placement, inpatient care, and after-care authorizations.
- Assess and manage discharge-planning needs for assigned patients, including Intensive Care Unit patients, until transfer to another level of care.
- Coordinate and collaborate with patients, families, nurses, physicians, case managers, and interdisciplinary healthcare team members on treatment and discharge plans.
- Review admissions and continued stays in accordance with the discharge plan and address utilization-management and quality-of-care issues.
- Assess patients who are substance abusers, homeless or uninsured, victims of domestic or elder abuse, or involved in child-abuse cases.
- Arrange or coordinate referrals for inpatient and outpatient terminal care and psychiatric care, and address needs of patients living in assisted living facilities, group homes, and adult homes.
- Coordinate community support services for patients newly diagnosed with cancer.
- Follow through on discharge plans for patients requiring guardianship.
- Provide discharge-planning support in the Emergency Department as necessary.
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What This Job Offers
Job Type
Full-time
