Discharge Planning Social Worker | Care Transitions

Northwesternmedicine; DeKalb (IL); On-site; USD 55,000 - 75,000; Full time

Job summary

Northwestern Medicine seeks a dedicated Social Worker Discharge Planner to ensure smooth transitions from hospital to home, coordinating discharge planning and social services for patients and families. You will work with the medical team to tailor plans, assess needs, and facilitate resources while addressing safety and regulatory requirements.

Responsibilities include coordinating care plans, monitoring information, and supporting Medicaid/Medicare processes to optimize patient outcomes and

Responsibilities

• Assure positive patient outcomes through coordinating the discharge planning and social service program identifying patients needing services after discharge with consideration given to normal characteristics of growth and development throughout the life span.
• Works collaboratively with the Medical Staff and other members of the healthcare team to ensure smooth transition and comprehensive discharge plans for their patient and their family.
• Monitors clinical information to support the assessment, treatment, education and continuity among healthcare providers and to enhance and improve individual and organizational performance in patient care.
• Institutes practice changes based upon findings from utilization review and utilization management benchmark data.
• Assures compliance with mandated Medicare/Medicaid initiatives.
• Acts as the hospital and community resource person to help people in the service area find appropriate services.
• Identification of patients at high risk for need of discharge services or assistance
• Use of SBAR and closed loop communication techniques
• Practicing national patient safety goals
• Maintains infection control standards
• Protects client's rights in accordance with the Illinois Mental Health code and all Healthcare laws.
• Working collaboratively as a member of the health care team and with the patient/family/significant other to develop a plan of continuing care compatible with patient needs, goals, and financial resources while giving consideration to the normal characteristics of growth and development throughout the life span.
• Family/significant other participation in patient care per patient request/approval.
• Complete all required forms in accordance with the Illinois Mental Health Code.
• Anticipates barriers to patient progress toward goals and performs ongoing assessment to identify patients with discharge needs, or changes in patient discharge needs.
• Complete the transfer of patients to other hospitals with appropriate psychiatric facilities per Physician/Psychiatrist order or at the request of the patient/family. All transfers will be in accordance with EMTALA and Cobra laws and hospital policies.
• Provide referrals based on financial needs and funding.
• Complete insurance pre-certification for psychiatric transfers and DMEs as needed and document necessary insurance information in Meditech and/or MIDAS.
• Understands and supports organizational goals regarding resource utilization as evidenced by Functioning as a resource to physicians and hospital staff regarding mental health laws and psychiatric services.
• Supporting and utilizing most effective staffing reflecting census/patient needs
• Identifying cost-saving measures
• Provide ongoing patient education including: Assessment of learning needs, abilities, preferences, and readiness
• Providing education relating to discharge planning, options, resources, utilization management, advance directives

Job description

Northwestern Medicine seeks a dedicated Social Worker Discharge Planner to ensure smooth transitions from hospital to home, coordinating discharge planning and social services for patients and families. You will work with the medical team to tailor plans, assess needs, and facilitate resources while addressing safety and regulatory requirements.

Responsibilities include coordinating care plans, monitoring information, and supporting Medicaid/Medicare processes to optimize patient outcomes and