Care Coordinator - Social Worker - SJ

Position Summary The Social Worker assumes responsibility and accountability for the collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's medical and psychosocial needs, using communication and available resources to insure quality, cost-effective outcomes. Closely monitors length of stay for all assigned patients. Education Master's Degree in Social Work

• Required Experience 2
• 3 Years medical social work
• Preferred License & Certification Licensed Clinical Social Worker (LCSW)
• Preferred Licensed Medical Social Worker (LMSW)
• Required within 2 years of hire National Certification in Case Management
• Preferred Core Job Functions Performs brief assessment, readmission risk assessment, and 6 clicks mobility assessment within one business day of admission.

Discuss discharge-planning needs with patient, family, and care team to determine most effective coordination of resources. Ensures patient/family/caregiver is aware of and agreeable to expected day of discharge. Reassess and document updates to discharge plan every 2 days including patient understanding or refusal of plan. Collaborates with Care Coordinators for complex-patient problem resolution. Resolves outstanding or unanticipated discharge issues through communication with patient, family, and care team. Schedule regular family conferences to maintain communication. Present and discuss high-risk complex patients at high risk LOS / Complex Care rounds with CCC leadership. Discuss barriers with the attending physician and if unsuccessful, escalate to leadership and Physician Advisor. Attends MDRs per department standard operating procedure. Provides GMLOS, actual LOS, and expected date of discharge for every patient each day. Focus MDR team's attention on identifying barriers to discharge and creating plan of action to address the barriers. Provide insights on appropriate patients status and level of care. Review action items created during MDRs and provide updates to Case Manager on SW Lead cases before the daily 2pm touchpoint meetings to determine resolution versus need for additional action. Identifies patients who are readmissions or at high risk of extending their stay beyond the GMLOS and take actions to minimize avoidable days. Documents avoidable days per department standard operating procedure. Maintains communication with care team by checking voice mail and email at minimum every 2 hours, completes required documentation by the end of the workday, adheres to on-call schedule and works holidays/covers weekend WOW absences as scheduled, and provides handoffs by email to team members as patients transition through the continuum of care. Provides weekend / on-call / PTO handoff. Maintains knowledge of laws regarding CPS/APS/Domestic Violence reporting as well as PASRR and 1013 changes/updates. Abide by NASW Social Work Code of Ethics. Consults with Social Work Supervisor for supervision when in need of education/guidance. Follows payer requirements and government regulations to ensure compliant, safe, and cost-effective care.