Social Work Care Coordinator - Per Diem

POSITION SUMMARY:

Responsible for assisting patients and their families with personal, financial and environmental difficulties predisposing to illness or interfering with obtaining maximum benefits from healthcare. Intervention is designed to enable patients and families to access and utilize healthcare in order to achieve their optimal level of health and functioning. This assistance is completed in the context of the patient's strengths and barriers, financial resources and family and environmental issues. Assessment, discharge planning, counseling, advocacy. Information/referral and follow-up monitoring are the basis of clinical social work intervention. In collaboration with the Case Coordinator (CC), the Social Worker facilitates the safe, effective and efficient discharge or disposition of patients. Additionally, the Social Worker participates in and supports the Hospital's and Medical Staffs Quality Improvement (PI) activities.

KEY RESPONSIBILITIES:

• Provides technical and educational guidance to the medical staff, nursing staff and hospital departments regarding Case Coordination, Social Service and discharge planning activities.
• Participates in performance measurement (PM) and PI activities.
• Participates in committees and PI projects as assigned.
• Contributes to the Department's and Hospital's mission by participating in pertinent community activities.
• Participates in mandatory education

Responsibility for Crises Intervention:

• Manages crisis or supports patients/families adjusting to life changes or issues related to drug and alcohol abuse, family dynamics, housing, mental health diagnoses, terminal illness, placement and maternal and child health as well as others.
• Identifies patients/families in crisis by assessing the patients and or familys needs using established criteria and by referrals from the CC or other member of the health team.
• Interviews patients and family member
• Collaborates, with other members of the health care team, with regard to emotional, social and financial aspects of care as an integral member of the interdisciplinary team.
• Provides crises intervention and patient/family counseling regarding placement outside the home and psychosocial issues.
• Covers the ER and accepts phone calls from the community, on a rotation basis, for crisis management
• Provides support to physician's offices, on a rotation basis, related to crisis management.
• Assists in verifying and resolving authorization of treatment issues.
• Coordinates the guardianship process.
• Reports suspected cases of abuse/neglect to the appropriate agency and when necessary, places children and adults in protective homes.
• Develops implements, coordinates and participates in various support groups.

• Maintains a comprehensive knowledge of community resources.
• Documents daily, all contacts with the patient and/or family related to intervention, referrals and/or legal proceedings.

Responsibility for Financial Issues:

• Addresses financial issues related to insurance as well as personal finances
• Refers patients and families to support groups, appropriate agencies providing community assistance and resources
• Manages all aspects of the Medicaid application process
• Document daily, contacts with the patient and/or family and any developments related to financial issues.

Responsibility for Performance Measurement and Improvement Activities:

• Participates in departmental PM and PI activities
• Concurrently collects and reports data as directed
• Instruct and participates in action planning and monitoring related to PI activities and external regulators feedback
• Consults/Assists the Medical and Hospital staffs in PM/PI activities
• Prepares statistical reports and special studies as assigned

Responsibility for Joint Commission Accreditation:

• Participates in site visit as assigned
• Understands and verbalizes role in applicable standards and mandatory education

Responsibility for Discharge Planning Activities:

• Conducts case finding for patients benefiting from participation in the Case Coordination Program
• Assesses the progress of the patient and plans for discharge
• Collaboration with other health care professionals in an effective and efficient Case Coordination approach to patient care
• In collaboration with the CC, issues notices of non-covered services.
• Assesses and identifies psychosocial barriers to discharge and implements appropriate intervention
• Collaborates with representatives for nursing home placements
• Maintains a comprehensive knowledge of community resources
• Acts as a consultant to physicians for nursing home placements from the community
• Assists in arranging services and equipment
• Documents daily, all contacts with the patient and / or family and any development related to discharge planning.

REQUIRED KNOWLEDGE & SKILLS:

• Demonstrated leadership ability
• Assessment and planning skills
• Working knowledge of Utilization, Case Coordination, Risk Management and PM/PI
• Ability to design a study, including criteria development
• Ability to complete a report of study findings
• Ability to report conclusions, analyze data and write an action plan to address recommendations
• Excellent written and oral communication skills with a demonstrated ability to communicate effectively
• Excellent interpersonal and organizational skills with the ability to function in a fast paced environment
• Understanding of Joint Commission standards related to the Continuum of Care; Patient Rights and Organizational Ethics; Education of Patients and Family; Management of Information; Infection Surveillance; Prevention and Control; Care of Patients; Assessment of Patients and Improving Organizational Performance.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

• Masters Degree from an accredited program.
• Licensed Social Worker in Massachusetts.
• Membership in a related professional organization, pursuing advanced educational preparation
• Minimum of 4 years clinical social work experience.