Continuing Care Liaison Licensed Clinical Social Worker, Full-time

Dartmouth-Hitchcock Health; Hartford (VT); Sur place; USD 72 000 - 95 000; Plein temps

Avantages offerts par ce poste

Employee Referral Bonuses

Clinical CEUs

Online LinkedIn Learning

Generous paid time off and holidays

Extensive health, dental, and life/ben

Résumé du poste

Dartmouth Health Home Care in Vermont seeks a Licensed Continuing Care Liaison (LICSW) to join a dedicated care team focused on smooth transitions from hospital to home. The role emphasizes assessment, care planning, and ensuring high-quality home health and hospice services for diverse patient populations.

You will collaborate with acute care and home-based teams, document care, and advocate for patient needs while supporting families throughout the transition process.

Qualifications

• Masters of Social Work is required.
• Minimum one year of experience in a health-related field.
• Collaborative team player with systems thinking, problem solving, creativity, and flexibility.
• Understanding of and comfort using computers is desired.

Responsabilités

• Be an integral member of a multi-disciplinary team providing continuity of care during transition from acute care to home.
• Document observations, interventions and evaluations related to patient care.
• Coordinate with discharge planners and providers to identify high-risk patients and ensure seamless transitions to Dartmouth Health Home Care.
• Educate prospective patients and families on home-based services and develop individualized care plans with involvement of patient and family.
• Advocate for patient needs and navigate complex systems to remove barriers in transitioning home.
• Monitor patient transitions across care settings to ensure health outcomes and patient/family success.
• Share assessment data and care plan information with patient consent as patients move through settings.
• Identify gaps in the care continuum and expand access via community and provider networks.
• Participate in development and coordination of an interdisciplinary care delivery system.
• Collect and evaluate data on patient satisfaction, health status, and resource use.

Connaissances

LICSW licensure

Interdisciplinary teamwork

Patient advocacy

Computer literacy

Formation

Masters of Social Work

Description du poste

Overview

Continuing Care Liaison LICSW

Full time - Days

Why work as an Continuing Care Liaison – Licensed Clinical Social Worker at the Dartmouth Health Home Care?

• You experience satisfying and challenging work that makes a difference, every day.
• You really get to know your patients and become an integral part of their care team.
• You are provided broad independence but are also part of a cohesive interdisciplinary team.
• You get to be an important part of the community where you live.
• You have a work/life balance that can match the flexibility you need.

Benefits include:

• Employee Referral Bonuses
• Clinical CEUs
• Online LinkedIn Learning
• Generous paid time off and holidays
• Extensive health, dental, and lifestyle benefits that come with being part of the renowned Dartmouth Health system

Locations:

• Upper Valley (Surrounding areas)

Dartmouth Health Home Care covers more than 70 towns delivering superior nursing, rehabilitation, hospice, and personal care services with proven effectiveness, integrity, and compassion. Our only goal is to help the people in our communities. When you join the Dartmouth Health Home Care, you’ll become part of a dedicated team delivering outstanding home health and hospice services that enrich the lives of the people we serve.

We would love to meet you and tell you more about this engaging and fulfilling part of our healthcare delivery system. Our Hiring Managers can explain the different roles, our service area, the unique aspects of home and hospice care, and the many benefits we can offer your career and personal life.

Responsibilities

As a Licensed Continuing Care Liaison - LICSW, you will be an integral member of a multi-disciplinary health care team that provides continuity of care in transitioning complex care patients from the acute care setting to home. This role partners with acute care setting interdisciplinary team in identifying patient/family needs and developing the plan of care to successfully transition home and continues to follow the patient, working with home-based care interdisciplinary team to ensure health outcomes are met and patient/family success at home.

• As an integral member of a multi-disciplinary health care team that provides skilled nursing, rehabilitative care and medical social work to patients, allowing them to receive the medical care required in the comfort of their own home.
• Accurately document observations, interventions and evaluations pertaining to patient care management and services.
• Works with discharge planners and referring providers to identify high risk patients and ensure a seamless transition to DHHC services.
• Provides information and education to prospective patients and families on home-based care services; performs a comprehensive patient/family assessment and in collaboration with the patient, family and care partners, develops a plan of care for transitioning the patient from the acute care center to home; provides continuing support and coordination for patient/family following transition home.
• Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in transitioning patient’s home.
• Monitors the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.).
• Shares assessment and physical, psychological, social and environmental care plan data with patient/family consent as the patient moves through different care settings.
• Identifies gaps in the care continuum and work with the community and provider networks to expand access to needed physical, psychological, social and environmental services.
• Participates in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization.
• Collects and evaluates data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization.

This job description is not meant to be exhaustive and may be modified as needed. Employees may be assigned other related duties to meet organizational needs.

Qualifications

• Masters of Social Work required
• Minimum one year experience in ahealth-related field required.
• Collaborative team player, use of systems approach in planning, problem solving and decision making, creativity, innovation, risk taking, autonomy, flexibility, receptiveness to change and a commitment to professional growth desired.
• Understanding of and comfort using computers desired.

Required Licensure/Certifications

• Must hold at least one active unencumbered LICSW license in either VT or NH at the time of hire. Employees must have active unencumbered LICSW licenses in both VT and NH within 30 days of their hire date.
• Valid driver’s license with a clean driving record
• Current car insurance, which meets minimum standards
• BLS within 90 days of hire

Salary ranges within each pay grade are based on qualifications, skills, experience, equity in comparison to similar positions, and external market values.