Care Coordinator Social Worker

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Day (United States of America)

The Care Coordination Social Worker (CC SW) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as a key resource for patients and serves as a consultant to the other care team members regarding patient's psychosocial and resource needs. In conjunction with the patient and physician, the CC SW will assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care.

Overall, the role integrates and coordinates the patients transitional care plan into their individualized discharge plans based on needs and resources available.

• Responsible for providing psychosocial assessments for patients to include timely and appropriate planning to advance the discharge plan.
• Assists in relaying information about community-based service offerings (e.g.
  
  -indigent care referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
• Serves as a specialist on issues related to psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
• Will partner and offer feedback to the RN Case Manager concerning complex social determinants of health issues, situational dynamics, and social needs.
• May have other duties assigned.

• Implements discharge planning and provides resource information in a timely and efficient manner for patients.
• Identifies and documents barriers for timely disposition.
• Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
• Responds to referrals for patient assistance from RN Care Coordinators, physicians and the care team.
• Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
• Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
• Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.
• Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning.
• Allows for any cultural or religious beliefs in providing service and continuity of care.
• Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes.

Implements discharge planning and provides resource information in a timely and efficient manner for patients.

Identifies and documents barriers for timely disposition.

Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.

Responds to referrals for patient assistance from RN Care Coordinators, physicians and the care team.

Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.

Initiates/facilitates post-acute…