Senior Care Coordination & Discharge Planner

2310 AU Medical Center, Inc.; United States; On-site; USD 70,000 - 95,000; Full time

Job summary

Wellstar Health System (Care Coordination Social Worker Sr.) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to ensure discharge plans meet needs. Serves as a consultant on psychosocial and resource needs, coordinating the discharge plan with the care team and physicians.

The role includes mentoring new social workers, precepting, and contributing to protocol development to optimize patient outcomes across the

Qualifications

• Excellent written and verbal communication skills.
• Knowledge of local, state and federal regulations relating to social work and healthcare.

Responsibilities

• Implements discharge planning and provides resource information in a timely and efficient manner for complex 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 transition.
• Responds to referrals for patient assistance from care coordinators and physicians.
• Participates in Interdisciplinary Rounds to confirm estimated discharge date and best level of transition.
• Initiates post-acute referrals through departmental processes for timely transition.
• Provides financial needs assessment for patients requiring follow-up care.
• Advocates and partners with patient and family to empower autonomous health decisions.

Skills

Communication skills

Education

Bachelor's in Social Work

Master's in Social Work (Preferred)

Job description

Wellstar Health System (Care Coordination Social Worker Sr.) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to ensure discharge plans meet needs. Serves as a consultant on psychosocial and resource needs, coordinating the discharge plan with the care team and physicians.

The role includes mentoring new social workers, precepting, and contributing to protocol development to optimize patient outcomes across the