Transitional Care Coordinator

San Francisco Campus for Jewish Living•San Francisco, CA

4h•$33

About The Position

As a member of the Social Services Department, the Social Worker/Transitional Care Coordinator is responsible for planning, organizing, developing and directing psychosocial interventions in accordance with applicable federal, state and local guidelines and regulations, and with Jewish Home and Rehab Center’s policies and procedures. Also responsible for applying professionally accepted, research-based practices, such as Person-Centered holistic approach, in working cooperatively as part of the interdisciplinary team to address resident and family psychosocial needs. Provides resident/patient advocacy as needed to achieve or maintain a dignified existence for all residents/patients. Facilitates transitions/discharges as needed and meets all documentation requirements.

Requirements

Master’s Degree in Social Work, Psychology, Counseling or related field.
Exemplary interpersonal skills and ability to work cooperatively as a member of a team.
Ability to communicate effectively with patients and their families, and at all levels of the organization.
Effective time management skills to organize and prioritize workload.
Understanding of Medicare/Medi-Cal guidelines.
At least two years of experience in healthcare and/or senior community experience.
Ability to lift, push, pull a minimum of fifteen (15) pounds.
Ability to exert maximum muscle force to lift, push, pull or carry
Ability to use abdominal and lower back muscles over time without fatigue
Ability to stand and/or sit for extended periods
Ability to bend, stoop, stretch, twist, sit, and reach
Fine motor skills
Good visual and auditory acuity

Nice To Haves

Knowledge of medical terminology preferred.
Language/Cultural proficiency of Russian or Chinese is preferred.

Responsibilities

Provides direct psychosocial interventions to residents and residents’ significant others.
Assists with residents, representatives/families and others in coping with skilled nursing placement, physical illness and disabilities of the resident, end of life and the grieving process.
Acts as primary liaison with psychosocial and psychiatric service providers.
Creates integrated, person-centered care plan based on resident’s strengths and preferences. Evaluates care plans for effectiveness of interventions, and updates as needed.
Documents observations and events in the resident’s medical record as needed; assesses and documents psychosocial impact of life events, health concerns and condition changes.
Provides educational materials to resident and/or family/significant others related to advance directives; assists in completion of advance directives as desired by resident and/or family/significant others.
Completes comprehensive psychosocial assessment of patients/residents.
Coordinates discharge planning as needed, working as a liaison between patients, their family, the interdisciplinary team, other departments and community referrals.
Responds to crisis situations as presented by patients, families, and staff.
Participates in coordination of care for patients/residents on comfort/palliative/hospice care. Provides sensitive interventions related to end of life care.
Provides/facilitates individual counseling to patients and families as needed.
Participates in the interdisciplinary formulation of patient care plans and develop goals and treatments for social work service.
Maintains accurate and timely documentation which complies with federal/state regulations and Jewish Home policy including but not limited to Initial Assessments, MDS/RAPS, Psychosocial/Mental Status Assessments, Care Plans, Social Service Progress Notes and Multidisciplinary conference forms.
Maintains confidentiality of necessary information.
Acts as a patient advocate and ensure patients are informed of their rights and responsibilities and insurance benefits, including changes that may affect their rights and responsibilities or insurance benefits.
Works collaboratively with Admissions Department to coordinate room transfers.
Coordinates with other unit social workers to ensure easy adjustment to another unit.
Participates in the facility Quality Assurance Performance Improvement (QAPI) program as assigned.
Other duties as assigned by Director of Social Services.