Responsible for coordinating clinically complex patient care needs across the Health Care continuum. Assess patients for transition needs including identifying patients at risk for readmission. Appropriate facilitation of high quality clinical and cost outcomes; negotiates, procures and coordinates services and resources needed by the patients in a time effective manner. Applies critical thinking and clinical knowledge to assess and advance patients¿ post-acute needs as well as to support patient flow within the hospital. Collaborates with Utilization Review in order to identify and address barriers to timely and efficient care delivery and reimbursement. Identifies and participates in the development of strategies to reduce unnecessary length of stay and/or resource consumption. Participates/facilitates in multidisciplinary rounding to address barriers to discharge, safe transition of care and effective communication within the care team. Completes all referrals to appropriate providers in a timely manner. Develops a detailed discharge plan in collaboration with the care team and patient/family input. Educates patient and family regarding care progression, appropriate post-acute level of care choices and available resources. Awareness of CMS regulations regarding discharge planning, Conditions of Participation, self-determination and community resources. Responds to suspected violence, assault, abuse and/or neglect cases in accordance with social work professional ethics. Completes initial discharge assessment tool for patients admitted within 24-48 hours of admission to forecast potential post-acute needs and develop appropriate discharge plans. Escalates cases as appropriate to Physician Advisor, Complex Care team and/or Ethics committee. Completes psychosocial assessment for Hi-Risk patients in order to facilitate appropriate care plans, reports and/or referrals.
Examples include but not limited to:
Abuse/Neglect, Substance Abuse, Behavioral Health Management and Human Trafficking.
Masters in Social Work from an accredited Institution. At least 2 years experience in an Acute Care setting. Positions in this classification require LMSW license or license eligibility in the State of Georgia. LCSW desirable. Knowledge of software applications.
(Medium): 20-50 lbs; 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 50 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
Factors affecting environment conditions may vary depending on the assigned work area and tasks.
Environmental exposures include, but are not limited to:
Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.