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Steward Health Care System Social Work Care Coordinator - Part-Time - Days in Norwood, Massachusetts

This is a 32 hour per week position working 7:00am to 3:30pm

POSITION SUMMARY The Social Work Care Coordinator is responsible the management of the social, emotional and financial wellbeing of the patients identified as needing the services of the Social Work Care Coordinator. The Social Work Care Coordinator is responsible for the discharge plan, and executing this plan including coordination of the services required by the patient upon discharge. They are responsible for exercising appropriate assessment of the patient and providing any psycho-social intervention as needed. The Social Work Care Coordinator will accept referrals from the outpatient areas and refer to community agencies as necessary. The Social Work Care Coordinator will provide education/consultation to the Nurse Managers and Nursing Staff to ensure achievement of quality patient outcomes.

RESPONSIBILITIES 1. Collaborates with the PCP to identify high-risk medical/social management patients. 2. Develop an individualized plan with the PCP for appropriate services for the patient. 3. Work collaboratively with the RN Care Coordinator to manage clinically complex discharges. 4. Daily rounds with RN Care Coordinator to discuss patients being overseen by both members of the Care Coordination Department. 5. Coordinate discharge/follow up activities. 6. Discuss with families the financial ramifications of their decisions and provide guidance in placement issues. 7. Provide individualized psychotherapy, supportive counseling and group therapy as needed. 8. Make referrals to community agencies when appropriate. 9. Identify potential legal or risk management issues and discuss with Director/Manager. 10. Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcomes. 11. Identify service needs, systems issues and opportunities for expansion of services. 12. Participate in continuing education programs that are relevant to job function. 13. Act as a patient advocate. 14. Document initial assessment, proposed plan, any changes to plan and final discharge plan in the medical record. 15. Documentation will be in a timely manner. 16. Communicate in a timely manner with Skilled Nursing Facilities, Community Health Agencies, Physicians and other staff. 17. Complete statistical reports as requested by supervisory staff. 18. With input from the RN Care Coordinator educate PCP’s and clinical staffs on alternative care options including high-tech home care, skilled nursing facility capabilities and disease management initiatives. 19. Educate patients regarding managed care and Medicare processes/regulations. 20. Provide patient teaching to patient and/or family. 21. Promote Social Work Care Coordinator services within legal, ethical and professional standards. 22. Demonstrate effective leadership skills. 23. Serve as a resource for members of the Care Coordination department. 24. Provide education/consultation as needed to other health care team members and to health care consumers. 25. Attend UMCM meetings as assigned and scheduled. 26. Participate in the facility Quality Improvement Plan through unit and/or divisional quality control/quality improvement activities. 27. Maintain current up to date knowledge of regulatory requirements. 28. Collaborate with other agencies for the education and benefit of the staff and hospital. 29. Represent the department on hospital wide teams for the betterment of service to the patients.

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