Continuing Care Coordinator (Social Work)

 

Assists in meeting the psychosocial needs of patients and families, through assessment of inpatients based on assignment. Patients are screened for continuing care needs, including emotional support, community resource needs, home care, Sub-acute and Acute Rehab placement as well as in patient care and after care authorizations. The Continuing Care Coordinator educates, coordinates, and collaborates with nurses, physicians, case managers and interdisciplinary members of the Healthcare team, to assure an ongoing comprehensive discharge plan.Ensures appropriate use of resources within an appropriate length of stay.  Collaborates with the multidisciplinary team on the patient’s treatment plan. Reviews admissions and continued stays in accordance with establishing discharge plan.   

Under the immediate supervision of the Director of Case Management, a successful employee must demonstrate competency in the following areas:

Reviews assigned units/patient’s and assesses the patient’s medical, social, financial, and psychological status within three days of patient’s admission. A CCC is assigned to assess all patients, including the Intensive Care Unit, and manages their discharge plan until the patient transfers to another level of care. The CCC, through assessment and reassessment, will collaborate, coordinate and manage the discharge planning needs of the patients assigned to them and review cases for quality of care and utilization management issues. CCC assesses patients for discharge planning needs, as well as patient’s that are substance abusers, homeless and uninsured patients, victims of domestic violence, elder abuse, and child abuse, patients who need referrals for inpatient and outpatient terminal care, inpatient and outpatient psychiatric care and patients living in assisted living facilities, group homes and adult homes. The CCC will be consulted for patients newly diagnosed with cancer for community support services. The CCC will be consulted for patients who require guardianship and the CCC will follow through on their discharge plan. A Case Manger and CCC are assigned to the Emergency Department for discharge planning as necessary.

 

Masters required in social work, LMSW or LCSW preferred.

Hospital experience required.New York State Screen Certification preferred.Able to read, write, speak, and understand the English language. Ability to communicate Spanish or community dominant language is desirable Effective professional rapport with physicians, patient, family/visitor, peers and supervisors. Sensitivity and Compassion.Knowledge of the services of the community, health, welfare, and social agencies.Demonstrates flexibility and creativity. Must be able to function well under pressure. Must have good leadership ability and good judgment. Must have good mental and physical health.Must be educated in the use of the particulate respirator (mask).