The social worker Care Coordinator is a member of the Care Coordination Department (a Hospital department) who educates the healthcare team and physicians about psychosocial issues and any identified patient/family problems as well as strategies to address the issues. Applies specialized knowledge and advanced practice skills in assessment, treatment, planning, implementation and evaluation, case management, mediation, counseling, supportive counseling, direct practice, information and referral, supervision, consultation, education, research, advocacy, community organization and developing, implementing and administering policies, programs and activities. This position will not apply specialized clinical knowledge and advanced clinical skills in assessment, diagnosis, and treatment of mental, emotional, and behavioral disorders, conditions and addictions, including severe mental illness and serious emotional disturbances in adults, adolescents, and children. This position integrates national standards for case management scope of services including: Care Coordination- A process whereby screening/identification, assessment, planning, sequencing of care and communication, when effectively integrated, ensure and advance the plan of care to support successful transitions. Compliance- Knowledge related to federal, state, local hospital and accreditation requirements that impact scope of services to include, Centers of Medicare and Medicaid Services (CMS) Condition of Participation. Transition Management- Planning that begins at the time of the initial patient encounter (preadmission, admission, emergency department, etc.) and is reevaluated and adjusted throughout the patient's hospital stay. Care Coordinators (both SW and RN) will arrange/ensure all elements of the transition plan are implemented and communicated to key stakeholders including, but not limited to, the health care team, patient/family/ caregiver, and post-acute providers. Care Coordinators will convey all necessary information for continuity of care and patient safety, verify receipt and provide a venue for additional questions and/or information requests/needs.
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Job Type
Full-time
Education Level
Master's degree
Number of Employees
5,001-10,000 employees