Care Coordinator SW Sr KHC
Wellstar Health System
Summary
The Care Coordination Social Worker Sr. (SW Sr) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's psychosocial and resource needs. In conjunction with the patient and physician, the SW Sr will assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care.
Job description
Core Responsibilities and Essential Functions
Assessment
- Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.
- Partners with the PAS, financial counselor, and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
- Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans.
Complex Disposition Planning
- Implements discharge planning and provides resource information in a timely and efficient manner for complex patients.
- Identifies and documents barriers for timely disposition.
- Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
- Responds to referrals for patient assistance from RN Care Coordinators, physicians and the care team.
- Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
- Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
- Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.
- Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning.
- Allows for any cultural or religious beliefs in providing service and continuity of care.
Documentation
- Initial psychosocial/functional assessment completed and documented in medical record.
- Ensure all records are up-to-date and documentation is understandable.
- Ensure timely and accurate documentation of progress notes and interactions with patient/family.
- Accounts for and indicates all services arranged/delivered in Electronic Health Record.
- Track avoidable days and report trends that lead to undesired outcomes.
Precepting/Mentoring
- Assist leadership with precepting new hires when needed.
- Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.
- Serves as a preceptor and/or mentor for student interns.
Professional Development and Initiative
- Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
- Supports departmental-based goals which contribute to the success of the organization.
- Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes.
Requirements
- Master's Degree in Social Work from an accredited college or university
- LMSW in State of GA (can be waived if have LCSW)
- Lic Clinical Social Worker GA or Lic Master Social Worker GA
- Basic Life Support or BLS - Instructor
- Minimum 2 years experience in healthcare in the acute care setting, related field or skilled care environment or community
- Excellent written and verbal communication skill
- Must possess maturity, self-confidence, objectivity, and positive attitude
- Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment
- Strong assessment, interview, organizational and problem-solving skills
- Knowledge regarding local, state and federal regulations required
- Knowledge of community and state-wide resources and programs
- Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care
Company overview
Wellstar Health System is one of Georgia's largest and most comprehensive integrated healthcare systems, founded in 1993 and headquartered in Marietta, Georgia. As a non-profit health system, Wellstar operates with a mission to enhance the health and well-being of every person it serves through its PeopleCare approach. The system employs approximately 29,469 to 33,000 team members across multiple hospitals, health parks, medical offices, outpatient centers, pediatric centers, nursing facilities, and hospice and home care services. Wellstar is nationally recognized for operating Georgia's largest integrated trauma network and features the second-largest Emergency Department in the United States. The organization provides more than $1 billion annually in charity care and community programs, demonstrating its commitment to community health. Wellstar has earned numerous accolades including recognition on Fortune's 100 Best Companies to Work For, Best Workplaces in Health Care, and PEOPLE Companies that Care lists. The system embraces innovation through its venture firm Catalyst by Wellstar, which nurtures early-stage healthcare companies, and maintains academic partnerships with institutions like the Medical College of Georgia for caregiver training. With specialties spanning cardiovascular care, oncology, women's health, pediatrics, musculoskeletal services, and numerous other medical disciplines, Wellstar delivers comprehensive healthcare across all stages of life.