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Responsible for acute care sites of service to assess, plan, facilitate, and integrate coordinated care for patients from preadmission or the ED through discharge. Develops a plan of care that supports post-discharge needs across the continuum. Addresses barriers, social determinants of health, high utilization of sites of service, and psychosocial and legal components affecting patients and their plans of care. Coordinates post-discharge services as applicable to patient needs, including placement, durable medical equipment, home health, personal care services, and other complex care support. Consults with multidisciplinary teams, committees, service lines, providers, and patients and families. Ensures compliance with state, federal, hospital, and TJC guidelines. Follows Case Management department standard work, including starting discharge planning on admission, timely documentation, education about the patient’s plan of care, reporting to Adult Protective Services or Child Protective Services, documentation supporting discharge planning, resource identification, and other assigned duties. The position may be filled by a BSW, MSW, or RN. BSW applicants must have a bachelor’s degree in social work or a related field and at least one year of social work experience. MSW applicants must have a master’s degree in social work or a related field and at least one year of social work experience. RN applicants must have an associate degree in nursing and at least two years of nursing experience; an advanced degree is preferred. Across these pathways, case management, home health, quality or utilization management, and community or hospital experience are preferred. BLS is preferred at hire and must be completed within three months of hire.
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Job Type
Full-time
Education Level
Associate degree

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