Social Work Care Coordinator: Discharge & Resources

Cape Fear Valley Health; Fayetteville (NC); On-site; USD 60,000 - 80,000; Full time

Job summary

Cape Fear Valley Health in Fayetteville, NC seeks a Social Worker to provide comprehensive psychosocial assessments, crisis intervention, and discharge planning. You will coordinate referrals, educate patients and families, and collaborate with the care team to ensure smooth transitions across the continuum of care.

Requires a BS in Social Work; MSW preferred. Three years of experience in social services and licensure/certification as CSW is preferred.

Qualifications

• Bachelor’s degree in Social Work required
• MSW preferred
• Professional Certification in Case Management or Social Work (CSW, CCM, or ACM) preferred

Responsibilities

• Conducts face-to-face interviews with patients and family members to develop therapeutic relationships and obtain psychosocial and financial information for discharge planning
• Performs proactive screenings and assessments for patients’ clinical, psychosocial, and discharge planning needs
• Documents assessment, the on-going plan, case progress, intervention(s), and reassesses patients as needed
• Initiates referrals and recommends consults to enable patient to be prepared for safe and timely discharge or transfer
• Assists patient/family in coping with hospitalization, disability, and chronic/terminal illness
• Utilizes communication, negotiation, and advocacy skills with patient, family, healthcare team and community
• Provides information, education to patient/family on community resources and options for post-acute care appropriate to the age of the patient served
• Caries out discharge planning activities to include providing arrangements for Home Health, Hospice, Home Infusion, DME, Outpatient Hemodialysis, Rehab, LTAC, Assisted Living, Rest Home and Skilled Nursing Facility placements
• Provides alternate plan of care options at the appropriate level of care based on patient/family needs and in collaboration with physician and/or designated team members
• Serves as a resource for processing issues such as guardianship, abuse, neglect, power of attorney, healthcare surrogate, advance directives or psychiatric involuntary commitment. Initiates/completes forms required for post-acute placement.
• Serves as a reliable resource for the Acute Care Nurse Navigator for difficult placements, information on Medicaid and disability, and Department of Social Service Referrals
• Consults with the Acute Care Nurse Navigator when clinical explanation of disease processes, clarification of physicians’ orders, and other pertinent information is needed to determine, safe appropriate discharge plan
• Other duties as assigned

Skills

Interpersonal communication

Time management

Team collaboration

Negotiation

Cultural competency

Documentation

Adaptability

Education

Bachelor's degree in Social Work

MSW preferred

CSW/CCM/ACM certification preferred

Tools

Microsoft Office

Midas

ProviderLink

ValleyLink

eHIM

SMS

Job description

Cape Fear Valley Health in Fayetteville, NC seeks a Social Worker to provide comprehensive psychosocial assessments, crisis intervention, and discharge planning. You will coordinate referrals, educate patients and families, and collaborate with the care team to ensure smooth transitions across the continuum of care.

Requires a BS in Social Work; MSW preferred. Three years of experience in social services and licensure/certification as CSW is preferred.