Social Worker Lmsw​/Discharge Planner

Social Worker (LMSW) / Discharge Planner

At The Hamlet Rehabilitation and Healthcare Center at Nesconset, residents are treated to a complete spectrum of Rehab Services and Clinical/Nursing Care. Our specialized in-house programs include short-term subacute Rehab and long-term care, short-term post hospitalization and post acute care, as well as Adult Day Health Services.

The Hamlet Rehabilitation and Healthcare Center at Nesconset is in search of a capable, hardworking and talented Social Worker (SW) / Discharge Planner to join our ever growing team.

Provides, coordinates and facilitates patient discharge planning in collaboration with other health care professionals Assist with organizing services across provider lines, between people, and systems to affect optimal patient outcomes, achieve continuity of care and reduce costs.

• Promote the mission, vision, and values of the organization and home healthcare.
• Identifies patients for teaching, discharge, to assisted living facilities.
• Collaborates with physicians, caregivers, patient, family, other departmental team members, and payor to proactively develop and implement a safe and appropriate discharge plan.
• Participates in team meetings that foster interdepartmental collaboration with the patient and their family as deemed necessary, this includes multidisciplinary meetings and Utilization Review/ Provides input in such meetings regarding utilization management and discharge planning.
• Applies utilization review criteria to assess continued stay, level of care, and readiness for discharge.
• Maintains working knowledge of Medicare, Medicaid and private insurance company coverage for referred products and services.
• Ensures that a quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the appropriate department; reports and identifies data that indicates potential areas for improvement of care and services provided within the system.
• Knowledgeable of patient’s financial status, diagnosis and discharge needs and documents these as an ongoing review.
• Maintains a current list of resources for referrals and refers to the appropriate inpatient, outpatient and community resources.
• Perform and complete follow up phone calls in a timely manner, provide referrals/ data according to the patient’s needs, ensure patient visits PCP.
• Participate and communicate with the care team in management of the patient through the ACO program and manage PMI Center Dashboard.
• Maintain HMO Log and transmit to Corporate weekly.
• Hold all short term care plan meetings initial and subsequent.

• Perform other duties as assigned

• Adhere to dress code, appearance is neat and clean.
• Complete annual education requirements.
• Maintain patient confidentiality at all times.
• Report to work on time and as scheduled.
• Wear identification while on duty.
• Maintain regulatory requirements, including all state, federal and local regulations.
• Represent the organization in a positive and professional manner at all times.
• Comply with all organizational policies and standards regarding ethical business practices.
• Communicate the mission, ethics and goals of the organization.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services.

• Current LMSW in the state of New York
• Experience in discharge planning and Utilization review preferred.
• Knowledge of Utilization management principles, HCFA guidelines, home health care, skilled nursing facilities/long term care and durable medical equipment is highly desirable.

• Knowledge of nursing services and insurance coverage preferred
• Strong organizational and interpersonal skills
• Ability to determine appropriate course of action in more complex situations
• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
• Ability to maintain confidentiality of all medical, financial, and legal information
• Ability to complete work assignments accurately and in a timely manner
• Ability to communicate effectively, both orally and in writing
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner

Salary up to $75,000