Care Coordinator SW

Socket.dev; Marietta (GA); On-site; USD 65,000 - 85,000; Full time

Job summary

Wellstar Health System is seeking a Care Coordination Social Worker to assess transitional care needs, coordinate across the continuum, and engage with patients and families to ensure discharge plans are safe and appropriate.

In collaboration with the care team and physicians, you will connect patients with community resources, support end-of-life planning when needed, and contribute to protocols and quality initiatives while maintaining compassionate care.

Qualifications

• Excellent written and verbal communication.
• Maturity, self-confidence, objectivity and a positive attitude.
• Self-directed with the ability to function well under stress.
• Strong assessment, interview, organizational and problem-solving skills.
• Knowledge of local, state and federal regulations.
• Knowledge of community and state-wide resources and programs.
• Ability to work collaboratively with physicians, care team, and patient/family to assist through the continuum of care.

Responsibilities

• 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 local, state, and federal resources to assist in planning a safe discharge.
• Responds to referrals for patient assistance from RN Care Coordinators and physicians.
• Participates in Interdisciplinary Rounds to confirm estimated date of discharge and make recommendations for best level of care transition.
• Initiates/post-acute referrals through departmental processes for timely transition to next level of care.
• Provides financial needs assessment for patients requiring assistance for follow-up care.
• Advocates for patient and family to empower them to make autonomous health care decisions.
• Respects cultural or religious beliefs in providing service and continuity of care.
• Participates in development of protocols, procedures and performance improvement to optimize patient outcomes.
• Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Skills

Communication skills

Stress management

Assessment skills

Interview skills

Organizational skills

Problem-solving

Regulations knowledge

Resources knowledge

Team collaboration

Education

BSW or MSW – Preferred

Job description

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work Shift

Day (United States of America)

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.

Specific functions within this role include:

Responsible for providing psychosocial assessments for patients to include timely and appropriate planning to advance the discharge plan.

Assists in relaying information about community-based service offerings (e.g.-indigent care referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.

Serves as a specialist on issues related to psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life. Will partner and offer feedback to the RN Case Manager concerning complex social determinants of health issues, situational dynamics, and social needs. May have other duties assigned

Core Responsibilities and Essential Functions:

• 2. Disposition Planning
  • a. Implements discharge planning and provides resource information in a timely and efficient manner for patients.
  • b. Identifies and documents barriers for timely disposition.
  • c. 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.
  • d. Responds to referrals for patient assistance from RN Care Coordinators, physicians and the care team.
  • e. Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
  • f. Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
  • g. Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.
  • h. 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.
  • i. Allows for any cultural or religious beliefs in providing service and continuity of care.
  • j. Participates in the development of protocols, procedures and performance improvement as indicatedto optimize patient outcomes.
• 1. Assessment
  • a. Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.
  • b. 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.
  • c. 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 patients care progression and discharge plans.
• 3. Documentation
  • a. Initial psychosocial /functional assessment completed and documented in medical record.
  • b. Ensure all records are up-to-date and documentation is clear and concise.
  • c. Ensure timely and accurate documentation of progress notes and interactions with patient/family.
  • d. Accounts for and indicates all services arranged/delivered in Electronic Health Record.
  • e. Track avoidable days and report trends that lead to undesired outcomes.
• 4. Professional Development and Initiative
  • a. Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
  • b. Supports departmental-based goals which contribute to the success of the organization.
  • c. Serves as a preceptor and/or mentor for social work students (if appropriate)
  • Performs other duties as assigned

Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Bachelors Social Work or Masters Social Work-Preferred

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

All certifications are required upon hire unless otherwise stated.

• BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor

Additional License(s) and Certification(s):

LCSW - Lic Clinical Social Worker GA Preferred orLMSW - Lic Master Social Worker GA Preferred

Required Minimum Experience:

Minimum 1 year of experience in healthcare in the acute care setting, related field or skilled care environment or community or educational internship in care coordination. Required orA background in medical social work in an acute care setting is highly Preferred

Required Minimum Skills:

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

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.