Facility: Behavioral Health Cobb

Job Summary:

The Care Coordinator is responsible for coordination of care for every patient from the time of admission until discharge from the hospital to the next level of care. This includes psychosocial and functional status assessment, individual, group and family therapy sessions, transitional care planning, patient advocacy, education for the patient/family, and assuring a safe and adequate discharge plan depending upon the patient's needs and resources. Collaborates with all team members to provide a comprehensive assessment of the patient's plan of care, goal/outcome attainment and continued care needs.

Core Responsibilities and Essential Functions:

Clinical Assessment and Care Planning (including Developmental Needs)
- Initiate and interpret thorough clinical assessments. Demonstrates skill in patient assessment that takes patients age and developmental needs into consideration when developing discharge and resource plans.
- Determine current mental status, history of present illness, financial status, living situation, support system and risk of harm to self or others and other information required according to the accrediting bodies.
- Verbalizes understanding of developmental needs of adult, and geriatric populations; is sensitive to these issues in assessment and care planning for patients and families.
- Demonstrates skill in assisting families with placement of patients in supervised living arrangements
- Based upon the initial and ongoing assessments, recommends the appropriate level of care and facilitates access to those services, i.e. further inpatient admission, outpatient services, residential placement.
- Consult with Physicians, Providers and other members of the treatment team regarding recommendations for further behavioral health services
- Review criteria and scope of services with the patient/guardian to ensure comprehension of program services available and provide recommendations.
- Recognizes indicators of suspected child/adolescent/disabled person/elder abuse and neglect, and follows mandated reporting policies and regulations.
- Documents psychosocial assessment information on appropriate electronic medical record screens or downtime paperwork.
- Partners with patient and family/support system to develop treatment plan based on patient/family needs, i.e., education, support, case management. Disposition Planning/Patient Education/Therapy Services
- Implements discharge planning in an appropriate, timely, and efficient manner.
- Attends multidisciplinary team meetings and care plan meetings to assist with disposition planning needs.
- Serves as patient advocate in the recovery/healing process.
- Provides resource information for patient/family to make appropriate plans for follow-up care.
- Understands eligibility processes and criteria for both private and public local, state, and federal resources.
- Completes necessary paperwork (including continuing care plan) and makes arrangements for transfer to appropriate level of care.
- Evaluates the effectiveness of the patients plan of care and makes revisions as needed
- Provides education and counseling for patients and families; provides individual and group therapy for patients; documents interventions.
- Develops and maintains productive working relationships with community agencies, nursing homes, personal care homes, and other resource centers.
- Demonstrates working knowledge of community resources.
- Responds to requests from hospital staff, provider offices, and community entities to provide resource information and education.
- Provides financial needs assessment and make appropriate referrals for patients in need of assistance.
- Provides follow-up for patients needing post-discharge assistance.
- Provides crisis intervention for patients, families.
- Understands pre-certification processes for acquiring services for patients needs (DME, home health, SNF, e.g.).
- Negotiates and refers for services outside of patients health plan, in collaboration with UR.
- Interfaces, as needed, with DFACS, APS, and other state regulatory agencies.
- Assists with patient/family complaint resolution and service recovery. Documentation
- Initial psychosocial/functional assessment completed and documented in the electronic medical record
- Documents the evaluation, treatment plan, ongoing reassessments, and safety plan
- Documents outcomes of every group therapy session for every patient who participated in group
- Documents each patient contact to address discharge plans and anticipated level of care
- Documents interactions with family/support systems
- Assists with legal documentation as needed for patient placement, i.e. 1021
- Attentive to detailed record keeping and completion of required paperwork General Requirements
- Adheres to ethical business practices by striving to perform in a manner that conforms to the highest standards of ethical behavior, integrity and honesty.
- Embraces diversity and demonstrates the ability to work together.
- Maintains confidentiality of all patient information.
- Maintains attendance/punctuality in accordance with system policy and procedure.
- Adheres to departmental dress code policy, including wearing and displaying ID badge appropriately.
- Communicates information effectively both verbally and in writing with all team members.
- Attends and participates in staff meetings, required inservices, process improvement activities, and other meetings as requested.
- Organizes workload to complete responsibilities in an appropriate and timely manner.
- Utilizes materials and equipment in a safe and cost-effective manner.
- Observes infection prevention precautions Customer Service
- Strives to help lead the industry through vision, technology, innovation and customer service.
- Strives to make a difference in the lives of our employees and patients.
- Consistently applies AIDET principles in all interactions with patients.
- Encourages a positive environment and experience for co-workers and patients. Treats patients and fellow team members with respect. Fosters teamwork with trust, support and collaboration.
- Demonstrates knowledge of service recovery principles and implements appropriately Professional Development
- Participates in professional development and mandatory education activities.
- Completes core and annual competencies according to established departmental timelines.
- Completes all educational requirements required by discipline to maintain licensure.
- Participates in orientation and training of new employees.
- Completes all mandatory hospital and/or system mandatory requirements

Required Minimum Education:

Master's Degree in Social Work, Required or
Counseling Required

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Lic Clinical Social Worker GA or Lic Master Social Worker GA or Master Social Worker or Reg Nurse (Single State) or RN - Multi-state Compact

Required Minimum Experience:

Minimum of one year of clinical practice/experience in general medical-surgical or behavioral health setting, Required

Required Minimum Skills:

Organizational and professional communication skills a must.
Ability to facilitate process groups with the patient population.
Ability to act as a liaison with multidisciplinary team members.