MSW Continuing Care Liaison — Home Health

Dartmouth Health; Hartford (VT); On-site; USD 67,000 - 104,000; Full time

Benefits offered by this job

Employee Referral Bonuses

Clinical CEUs

Online LinkedIn Learning

Generous paid time off and holidays

Extensive health, dental, and life/ret

Job summary

Dartmouth Health Home Care seeks a Continuing Care Liaison – MSW to join our team in Hartford, VT. This full-time, days role works within a multi-disciplinary care team to coordinate transitions from acute care to home and hospice settings.

You will document care plans, educate patients and families, and advocate to remove barriers across care settings. Strong collaboration, problem-solving, and flexibility are essential to success.

Qualifications

• Masters of Social Work required.
• Minimum one year experience in a health-related field.
• LICSW in NH and VT preferred.

Responsibilities

• Be an integral member of a multi-disciplinary health care team to transition complex patients from acute to home care.
• Document observations, interventions and evaluations pertaining to patient care management.
• Identify high risk patients with discharge planners to ensure seamless transitions.
• Provide information and education to patients and families on home-based care and develop a plan of care.
• Advocate for patient needs and remove barriers in transitioning home.
• Monitor transitions across care settings and share care plan data with consent.
• Identify gaps in care and expand access via community and provider networks.
• Participate in development and coordination of an interdisciplinary care delivery system.
• Collect and evaluate data/outcomes such as patient satisfaction and health status.

Skills

Collaborative

Team player

Systems thinking

Problem solving

Autonomy

Flexibility

Education

Masters of Social Work

Tools

Computers

Job description

Dartmouth Health Home Care seeks a Continuing Care Liaison – MSW to join our team in Hartford, VT. This full-time, days role works within a multi-disciplinary care team to coordinate transitions from acute care to home and hospice settings.

You will document care plans, educate patients and families, and advocate to remove barriers across care settings. Strong collaboration, problem-solving, and flexibility are essential to success.