Continuing Care Liaison Licensed Clinical Social Worker, Full-time

Dartmouth Health•White River Junction, VT

About The Position

Dartmouth Health Home Care is hiring a full-time, day-shift Continuing Care Liaison Licensed Clinical Social Worker (LICSW) serving the Upper Valley and surrounding areas. The liaison is an integral member of a multidisciplinary healthcare team, helping complex-care patients transition from acute care to home and supporting their continued care after the transition. The role partners with acute-care teams to identify patient and family needs, develop transition plans, coordinate services, and work with home-based care teams to support successful outcomes. It also contributes to skilled nursing, rehabilitation, and medical social work services that enable patients to receive care at home. Dartmouth Health Home Care serves more than 70 towns and provides nursing, rehabilitation, hospice, and personal care services. The organization describes the role as offering meaningful work, patient relationships, broad independence within a cohesive interdisciplinary team, community involvement, and work-life flexibility.

Requirements

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

Nice To Haves

Collaborative team player.
Uses a systems approach to planning, problem solving, and decision making.
Creativity, innovation, and willingness to take risks.
Autonomy and 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 from acute care to home.
Work with discharge planners and referring providers to identify high-risk patients and support seamless transitions to Dartmouth Health Home Care services.
Provide prospective patients and families with information and education about home-based care services.
Conduct comprehensive patient and family assessments and collaborate with patients, families, and care partners to develop transition plans.
Provide ongoing support and care coordination to patients and families after they transition home.
Advocate for patient needs and navigate complex systems to address barriers to transitioning home.
Monitor patients’ transitions across and within care settings, including home, clinics, skilled nursing facilities, rehabilitation, and hospitals.
With patient and family consent, share assessment and care-plan information concerning physical, psychological, social, and environmental needs 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 an interdisciplinary care delivery system tailored to individual patient needs and effective resource use.
Collect and evaluate outcomes, including patient satisfaction, health and functional status, and resource utilization.
Accurately document observations, interventions, and evaluations related to patient care management and services.
Perform other related duties as assigned to meet organizational needs.