Job Summary:

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.

Core Responsibilities and Essential Functions:

Disposition Planning

- 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 patient’s 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. Assessment

- Based on preliminary screening of patients, initiates assessment of patient’s psychosocial risk factors and availability of resources to assist upon discharge.
- Partners with the PAS, financial counselors and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
- Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patient’s care progression and discharge plans. Documentation

- Initial psychosocial /functional assessment completed and documented in medical record.
- Ensure all records are up-to-date and documentation is clear and concise.
- Ensure timely and accurate documentation of progress notes and interactions with patient/family.
- Accounts for and indicates all services arranged/delivered in Electronic Health Record.
- Track avoidable days and report trends that lead to undesired outcomes. Professional Development and Initiative

- Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
- Supports departmental-based goals which contribute to the success of the organization.
- Serves as a preceptor and/or mentor for social work students (if appropriate)

Required Minimum Education:

Master's Degree in Social Work or a master’s degree in Social Work from an accredited college or university. LMSW in the State of GA (can be waived if have LCSW) Required

Required Minimum License(s) and Certification(s):

Basic Life Support 1.00 Required
BLS - Instructor 1.00 Preferred
BLS - Provisional 1.00 Preferred
Lic Master Social Worker GA 2.00 Required
Lic Clinical Social Worker GA 2.00 Required

Additional Licenses and Certifications:

Required Minimum Experience:

Minimum 3 years of experience in healthcare (hospital) in the acute care setting, related field or skilled care environment or community or educational internship in care coordination. Required and
Minimum 2 years A background in medical social work in an acute care setting Preferred

Required Minimum Skills:

Excellent written and verbal communication skill. High
Must possess maturity, self-confidence, objectivity, and positive attitude. High
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment High
Strong assessment, interview, organizational and problem-solving skills. High
Knowledge regarding local, state and federal regulations required. High
Knowledge of community and state-wide resources and programs. High
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care. High