Senior Care Coordinator - Cancer Center - Augusta

Wellstar Health System

12d

About The Position

The Senior Care Coordinator (Care Coordination Social Worker Sr.) assesses transitional care needs, coordinates care across the continuum, and engages patients and families to ensure care needs are met. The role is an expert resource for complex patient situations and consults with care team members on patients’ psychosocial and resource needs. In partnership with patients and physicians, the Senior Care Coordinator assesses, coordinates, and implements timely, safe discharge plans to appropriate next levels of care, integrating each patient’s transitional care plan with their individualized discharge plan and available resources. The position provides psychosocial assessments and timely discharge planning; shares information about community services and helps patients and families navigate factors affecting their psychosocial circumstances; and provides expertise on psychosocial and discharge needs, end-of-life planning, and resources. The role partners with RN Care Coordinators on complex social needs and may participate in orientation, precepting, and mentoring social work colleagues and student interns. The Senior Care Coordinator plans complex dispositions, identifies barriers, evaluates resource eligibility, responds to referrals, participates in interdisciplinary rounds, facilitates post-acute referrals, and assesses financial needs for follow-up care. The role collaborates with patients, families, physicians, and other care team members; completes and maintains timely, accurate documentation in the electronic health record; tracks avoidable days; completes required competency and education activities; supports departmental goals and performance improvement; and complies with Wellstar policies, standards of work, and code of conduct. Other duties may be assigned.

Requirements

Bachelor’s degree in Social Work required; Master’s degree in Social Work preferred.
Georgia LMSW (Licensed Master Social Worker) or Georgia LCSW (Licensed Clinical Social Worker) required upon hire.
BLS, ARC-BLS, or BLS-I certification required upon hire.
At least 2 years of experience in healthcare in an acute care setting, a related field, a skilled care environment, or the community.
Excellent written and verbal communication skills.
Maturity, self-confidence, objectivity, and a positive attitude.
Ability to work independently, function under stress, handle change, and work in a fast-paced environment.
Strong assessment, interviewing, organizational, and problem-solving skills.
Knowledge of applicable local, state, and federal regulations.
Knowledge of community and statewide resources and programs.
Ability to collaborate with physicians, care team members, patients, and families throughout the continuum of care.

Nice To Haves

Master’s degree in Social Work.
Background in medical social work in an acute care setting.

Responsibilities

Provide psychosocial assessments and timely planning to advance patient discharge plans.
Share information about community-based services and guide patients and families through psychosocial and resource-related factors.
Provide expertise and resource information concerning psychosocial needs, discharge planning, end-of-life care, and decision-making.
Partner with RN Care Coordinators on complex social determinants of health, situational dynamics, and social needs.
Implement discharge planning and provide resource information for complex patients.
Identify and document barriers to timely disposition.
Apply eligibility processes and criteria for private and public local, state, and federal resources when planning safe transitions.
Respond to patient-assistance referrals from RN Care Coordinators, physicians, and the care team.
Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend appropriate levels of care.
Initiate and facilitate post-acute referrals through departmental processes.
Assess financial needs for patients requiring follow-up care across the continuum.
Advocate for patients and families and support autonomous decisions that center the patient’s wishes.
Respect cultural and religious beliefs in service delivery and continuity of care.
Assess psychosocial risk factors and available discharge resources based on preliminary patient screening.
Partner with the PAS, financial counselor, and/or UM nurse to assess insurance and coverage requirements.
Collaborate with patients, families, physicians, and other care team members to support care progression and discharge plans.
Complete and document initial psychosocial and functional assessments in the medical record.
Maintain current, understandable records and complete timely, accurate progress notes and interaction documentation.
Record services arranged or delivered in the Electronic Health Record.
Track avoidable days and report trends contributing to undesired outcomes.
Assist leadership with precepting new hires when needed.
Mentor less senior employees in challenging patient and family situations.
Serve as a preceptor and/or mentor for student interns.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Support departmental goals and participate in developing protocols, procedures, and performance improvement activities.
Comply with Wellstar policies, standards of work, and code of conduct.
Perform other duties as assigned.