Assesses, plans, implements, coordinates, monitors, and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes.

Completes patient assessments to identify barriers to discharge with a focus on social determinants of heath, patient’s ability for self-care, or any potential post-hospital services that may be required at discharge.

Identifies any psychosocial, clinical, cultural, spiritual, or financial barriers that may impede a safe effective transition from the hospital.

Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes.

Initiates care coordination strategies that are evidence-based and outcome focused.

Collaborates with the multidisciplinary team to formulate a safe discharge team.

Utilizes the readmission risk tool to identify barriers to effective discharge plan.

Identifies patient care requirements by establishing personal rapport with patients, families, and caregivers.

Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients and families.

Ensures safe and effective transitions of care that help to promote positive health care outcomes while focusing on social determinants of health that affect a patient’s overall well-being.

Promotes patient's independence by working to transition to the least restrictive level of care and establishing goals of care with patient, family, and caregiver.

Has knowledge of resources in the area such as post-acute providers, home health agencies, hospice, LTACH, IP rehab, assisted living, skilled nursing facilities, DME, etc.

Arranges for post hospital services prior to discharge and ensure they are done timely to avoid delays in discharge. Acts as the liaison between the patient, hospital, and post hospital services.

Maintains a safe and clean working environment by complying with environmental procedures, rules and regulations.

Demonstrates competencies of critical-thinking skills for transitioning complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally sensitive discharge planning.

Maintains professional knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies.

Protects patients and employees by adhering to infection-control policies and protocols

Assures care coordination that considers patients' values, needs, preferences and their choice to self-direct care.

Maintains patient confidence and protects operations by keeping information confidential and abiding by HIPPA standards.

Put the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time.

Effectively manages transitions involving comprehensive planning, targeted outreach and the timely transfer of information between parties critical to the transition. Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes.

Facilitates the flow of care to expedite an appropriate discharge and prevent readmissions.

Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team continuous quality improvement and problem-solving methods.

Ensures complete, accurate, timely and appropriate documentation of patient assessment, and any information for the discharge plan.

Communicates discharge plan to members of the health care team via attendance at SIBR rounds, concurrent documentation, and verbal communication.

Evaluates and projects discharge planning needs and coordinates post-acute care needs of patient in assigned case load.

Coordinates post-hospital needs in a timely and effective manner.

Apply advanced interpersonal skills in negotiating appropriate plans of care needs for assigned patient population.

Acts as a resource/consultant to internal customers for extensive knowledge of community resources and expertise in accessing social/community systems.

Reviews the laws and regulations that influence the practice of social work. Has working knowledge of Advanced Directives, HIPAA, and health care proxy formats.

Works with legal team for potential guardianship or adoption cases.

Other duties as assigned.

Competency and Experience [Knowledge, Skills and Abilities]

Required Qualifications/Experience

Master’s degree in social work.

Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects.

Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.

Knowledge of Payor/Insurance Benefits

Functional Skills on PC and Related Software (Microsoft Office)

Knowledge of basic Office Equipment such as copier, fax machine, etc.

Preferred Qualifications/Experience

Experience in Acute Healthcare setting.

License, Certification & Clearances

Act 33 with renewal

Act 34 with renewal

Act 73 FBI Clearance with renewal

Case Management Certification preferred

LSW or LCSW preferred

Position Type/Expected Hours of Work

Incumbent will be scheduled based on operational need (rotate shifts, standby, on-call, etc.).

Travel may be expected locally between System locations.

Equal Employment Opportunity

Independence Health and its affiliated companies are Equal Opportunity Employers. It is their policy to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants without regard to race, color, religion, sex, sexual orientation, national origin, age, marital status, disability, veteran status, or genetic information, or any other classification protected by law. Independence Health and its affiliated companies will comply with all applicable laws and regulations.

Disclaimer

This job description is not designed to contain a comprehensive listing of all activities, duties or responsibilities that are required of the employee. Moreover, duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Work Environment: Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Essential – Absolute Necessity.

Marginal – Minimal Necessity.

Constantly – 5.5 to 8 hours or more or 200 reps/shift.

Frequently – 2.5 to 5.5 hours or more or 32-200 reps/shift.

Occasionally – 0.25 to 2.5 hours or 2-32 reps/shift.

Rarely – Less than 0.25 hours or less than 2 reps/shift.

Physical Condition

Essential

Marginal

Constantly

Frequently

Occasionally

Rarely

Never

Extreme Heat

x

x

Extreme Cold

x

x

Heights

x

x

Confined Spaces

x

x

Extreme Noise(>85dB)

x

x

Mechanical Hazards

x

x

Use of Vibrating Tools

x

x

Operates Vehicle

x

x

Operates Heavy Equipment

x

x

Use of Lifting/Transfer Devices

x

x

Rotates All Shifts

x

x

8 Hours Shifts

x

x

10-12 Hours Shifts

x

x

On-Call

x

x

Overtime(+8/hrs/shift; 40/hr/wk)

x

x

Travel Between Sites

x

x

Direct Patient Care

x

Respirator Protective Equipment

x

x

Eye Protection

x

x

Head Protection (hard hat)

x

x

Hearing Protection

x

x

Hand Protection

x

x

Feet, Toe Protection

x

x

Body Protection

x

x

Latex Exposure

x

x

Solvent Exposure

x

x

Paint (direct use) Exposure

x

x

Dust (sanding) Exposure

x

x

Ethylene Oxide Exposure

x

x

Cytotoxic (Chemo) Exposure

x

x

Blood/Body Fluid Exposure

x

x

Chemicals (direct use) Exposure

x

x

Mist Exposure

x

x

Wax Stripper (direct use)

x

x

Non-Ionizing Radiation Exposure

x

x

Ionizing Radiation Exposure

x

x

Laser Exposure

x

x

Physical Demands

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Essential – Absolute Necessity.

Marginal – Minimal Necessity.

Constantly – 5.5 to 8 hours or more or 200 reps/shift.

Frequently – 2.5 to 5.5 hours or more or 32-200 reps/shift.

Occasionally – 0.25 to 2.5 hours or 2-32 reps/shift.

Rarely – Less than 0.25 hours or less than 2 reps/shift.

Physical Condition

Essential

Marginal

Constantly

Frequently

Occasionally

Rarely

Never

Bending (Stooping)

x

x

Sitting

x

x

Walking

x

x

Climbing Stairs

x

x

Climbing Ladders

x

x

Standing

x

x

Kneeling

x

x

Squatting (Crouching)

x

x

Twisting/Turning

x

x

Keyboard/Computer Operation

x

x

Gross Grasp

x

x

Fine Finger Manipulation

x

x

Hand/Arm Coordination

x

x

Pushing/Pulling(lbs. of force)

x

x

Carry

x

x

Transfer/Push/Pull Patients

x

x

Seeing Near w/Acuity

x

x

Feeling (Sensation)

x

x

Color Vision

x

x

Hearing Clearly

x

x

Pulling/Pushing Objects Overhead

x

x

Reaching Above Shoulder Level

x

x

Reaching Forward

x

x

Lifting Floor to Knuckle

10-19#

x

x

Lifting Seat Pan to Knuckle

###

x

x

Lifting Knuckle to Shoulder

###

x

x

Lifting Shoulder to Overhead

###

x

x

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.