Continuing Care Liaison Licensed Clinical Social Worker, Full-time

Dartmouth-Hitchcock Health • Claremont, NH

5d

About The Position

The Continuing Care Liaison Licensed Clinical Social Worker is an integral member of a multidisciplinary health care team, helping complex-care patients transition from an acute care setting to home. The liaison works with acute-care interdisciplinary teams to identify patient and family needs and develop a plan for a successful transition, then follows patients after they return home in partnership with home-based care teams to support health outcomes and patient and family success.

The role supports the delivery of skilled nursing, rehabilitative care, and medical social work in patients’ homes. It includes assessing and educating patients and families, coordinating care across settings, advocating for patient needs, and collaborating with community and provider networks to address gaps in care. The position is full-time, days, serving the Upper Valley and surrounding areas.

Requirements

• Master of Social Work degree.
• At least one year of experience in a health-related field.
• At least one active, unencumbered LICSW license in Vermont or New Hampshire at the time of hire.
• Active, unencumbered LICSW licenses in both Vermont and New Hampshire within 30 days of the hire date.
• Valid driver’s license and clean driving record.
• Current car insurance that meets minimum standards.
• BLS certification within 90 days of hire.

Nice To Haves

• Collaborative team-player approach.
• Use of a systems approach in planning, problem solving, and decision making.
• Creativity, innovation, risk taking, autonomy, flexibility, receptiveness to change, and commitment to professional growth.
• Understanding of and comfort using computers.

Responsibilities

• Partner with acute-care interdisciplinary teams to identify patient and family needs and develop plans for transitioning complex-care patients to home.
• Provide information and education to prospective patients and families about home-based care services.
• Conduct comprehensive patient and family assessments and, in collaboration with patients, families, and care partners, develop transition plans.
• Provide ongoing support and care coordination following patients’ transitions home.
• Accurately document observations, interventions, and evaluations related to patient care management and services.
• Work with discharge planners and referring providers to identify high-risk patients and support seamless transitions to Dartmouth Health Home Care services.
• Advocate for patient needs and negotiate complex systems to remove barriers to transitioning home.
• Monitor patient transitions across and within care settings, including home, clinic, skilled nursing facilities, rehabilitation, and hospitals.
• Share assessment and physical, psychological, social, and environmental care-plan information with patient and family consent as patients move between care settings.
• Identify gaps in the care continuum and work with community and provider networks to expand access to needed services.
• Participate in developing, maintaining, and coordinating interdisciplinary care delivery tailored to individual patient needs and effective resource use.
• Collect and evaluate data and outcomes, including patient satisfaction, health and functional status, and resource utilization.

Benefits

• Employee referral bonuses.
• Clinical continuing education units (CEUs).
• Online LinkedIn Learning.
• Generous paid time off and holidays.
• Health, dental, and lifestyle benefits through the Dartmouth Health system.
• Work-life balance and flexibility.

What This Job Offers

• Job Type: Full-time