JOB SUMMARY

This job is responsible for working in concert with a provider/interdisciplinary team to assist in providing care coordination across the healthcare continuum in accordance with a plan of care that meets identified needs and incorporates services/resources that will facilitate improved outcomes and quality of daily life. An incumbent performs psychosocial and other screenings for review by the Registered Nurse Care Manager. They may provide information/guidance to the patient/family for effective care transition, improved self-management skills and to reinforce the need for active participation in maximizing overall health. Care transition is conducted primarily through telephonic communication and patient clinic visits. Work is focused on selected patient populations.

Work includes:

• Identifying the psychosocial needs of post-acute care patients, including completing psycho-social screening of the patient and evaluating the patient’s level of functioning;
• Assisting RN in coordinating and monitoring patient care between provider visits;
• Assisting patients in obtaining prescribed medications, making appointments for services, arranging for home medical equipment, completing various care-related forms and similar activities;
• Collecting, updating and communicating patient information which could impact the plan of care; and
• Identifying community and other resources and connecting patients with services that address needs and gaps in the healthcare continuum, improve outcomes and facilitate overall achievement of self-management goals.

Education/Work Experience Requirements

Bachelor’s degree in social work, psychology, geriatrics, or related field and one year of related work experience that would demonstrate attainment of the requisite job knowledge/abilities. Work experience in case management, social work or discharge planning is preferred.

Licensure/Certification

• Eligible for Agency Affiliated Counselor prior to date of hire and credential obtained within 60 days of hire, OR
• Current Licensed Social Workers Association Independent Clinical (LSWAIC).