Social Worker- Housing Coordinator (Full Time, Day)

455 Independent Living for Seniors; United States; On-site; USD 73,068,000 - 100,289,000; Full time

Benefits offered by this job

Housing coordination

Care coordination

Discharge planning

Insurance advocacy

Interdisciplinary collaboration

Job summary

Rochester Regional Health in Rochester, NY, is seeking a Social Work Housing Coordinator to support ElderONE Housing Coordination. You will work with care teams to assess patient needs, coordinate housing options, and facilitate timely discharges with community partners.

The role requires a BS in Social Work, one year of healthcare experience preferred, and strong documentation, communication, and advocacy skills to obtain insurance coverage and coordinate transitions.

Qualifications

• Bachelor’s degree in Social Work or related degree required.
• One year of healthcare setting experience preferred.
• Strong documentation and care coordination skills.
• Excellent communication and interpersonal skills.

Responsibilities

• Coordinate patient care through rounds, chart reviews, and team conferences.
• Manage referrals and determine intervention strategies for insurance coverage.
• Develop and implement care plans in line with social work policy.
• Discharge planning and continuation of care arrangements.
• Coordinate housing options and transitions for ElderONE participants.
• Advocate with health insurers to obtain coverage approvals.

Skills

Healthcare experience

Compassionate

Documentation

Communication skills

Interpersonal skills

Care coordination

Education

BS: Social Work (Required)

Human-services related major

Job description

SUMMARY As a Social Worker, you play an important and trusted role in the lives of patients and their family. You are an integral part of their care and recovery.

LOCATION: ElderOne Hudson

POSITION: Social Work Housing Coordinator

SCHEDULE: M-F 8-4:30PM

ATTRIBUTES

• One (1) year of experience in a healthcare setting preferred
• Compassionate, warm and patient focused
• Exceptional documentation and planning skills
• Excellent communication and interpersonal skills

RESPONSIBILITIES

Patient Care. Determine patient needs through rounds, chart review, patient/family interviews and team conferences; coordinate multidisciplinary and agency case conferences; work with care managers to advocate for patient/family to obtain approval for insurance coverage Referral Management. Manage referrals related to patients at risk and determine appropriate intervention strategies and document as implemented; ensure inappropriate referrals are channeled correctly and documented Treatment Plan Development. Coordinate assessments and develop care plan in accordance with accepted social work policy; implement plan of intervention preparatory to discharge or initiate continued care plan

Key Responsibilities

• Manages referrals related to patients with psychosocial needs and determines appropriate interventions and strategies to meet those needs.
• Reviews track board census or documentation to identify high risk patients not referred.
• Determines patient needs through interdisciplinary rounds, chart review, patient/family interviews and team conferences.
• Documents social work intervention.
• Ensures that all inappropriate referrals are channeled correctly and documented.
• Assesses patient needs and determines mode of intervention.
• Possesses appropriate age and specific knowledge about the dynamics of group assigned and assesses patient needs accordingly as documented in Care Connect or medical record.
• Interviews patients and/or families and records psychosocial assessments in accordance with the social work documentation policy as documented in chart.
• Coordinates assessments and develops care plans in accordance with accepted social work policy as documented in chart.
• If indicated, evaluates patients for the appropriate level of care as documented in chart, office file, and by referrals.
• Coordinates multidisciplinary and agency case conferences as needed, as verified through chart notes indicating attendance, problems discussed and treatment plan.
• Implements plan of intervention preparatory to discharge or initiating continued care plan in compliance with departmental and governmental regulations.
• Works with care manager, acts as intermediary, with Health Care Insurance providers (ex. HMO’s, private insurance, Medicare), advocating for patient/family, to obtain approval for coverage as documented in the chart.
• Involves patient/family in the treatment planning process as demonstrated in the chart notes, and signatures on the appropriate forms.
• Executes plan of discharge/continued care which is mutually agreeable to patient/family.
• Notifies involved parties (ex., doctor, family, patient, facility) concerning the discharge, within 24 hours of receipt of discharge authorization as documented in chart.
• Requests needed paperwork from nursing/doctor other disciplines as documented in the chart.
• Arranges for transportation of patient where needed in accordance with hospital procedure, as documented in the chart.
• Acts as liaison with the community and as a referral source.
• Performs other duties as assigned.

For ElderONE Housing Coordination, the responsibilities include

• Eliminate wasted beds days in the hospital and skilled nursing facility that are due to housing barriers.
• Build effective relationships in order to creates housing options for ElderONE that vary in length of stay (short term vs long term vs permanent) and in the services they provide.
• Coordinate with interdisciplinary teams, discharge planners and other RRH and non RRH partners to ensure well-coordinated and timely discharges/transitions into housing as needed.
• Assists participants with all aspects of establishing housing (tours, documentation and paperwork, finances (rent, deposits, rep payee if needed)
• Has a good pulse on participa.nts at risk for homelessness and creates proactive mitigation plans that prevents the need to use skilled nursing or unnecessary higher levels of care.
• Works with contracted and non-contracted skilled nursing facilities to provide housing options for patients who no longer desire a skilled nursing facility.

Minimum Qualifications

• For those hired on or before December 31, 2023, a Bachelor’s Degree in Social Work or related degree is required.
• For those hired on or after January 1, 2024, a Bachelor’s Degree in Social Work is required.

Long Term Care Minimum Qualifications

• Minimum of a Bachelor’s degree in social work; OR
• Minimum of a Bachelor’s degree in a human-services related major, including sociology, gerontology, psychology, rehabilitation counseling or special education; AND One year in a healthcare setting where the individual is working as a supervised social worker who works directly with individuals.

New Graduates

• Official transcript from accredited school or letter emailed directly from the school’s registrar’s office confirming program completion will be accepted upon graduation.
• Primary source education verification required within 90 days of start date.

EDUCATION

BS: Social Work (Required)

PHYSICAL REQUIREMENTS

S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE

$25.50 - $35.00 CITY: Rochester POSTAL CODE: 14617 The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law. Rochester Regional Health is an integrated health services organization serving the people of Western New York, the Finger Lakes, St. Lawrence County, and beyond. The system includes nine hospitals; primary and specialty practices, rehabilitation centers, ambulatory campuses and immediate care facilities; innovative senior services, facilities and independent housing; a wide range of behavioral health services; and Rochester Regional Health Laboratories and ACM Global Laboratories, a global leader in patient and clinical trials. It’s vision is to lead the evolution of healthcare to enable every member of the communities it serves to enjoy a better, healthier life.