Hartford HealthCare at Home
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DescriptionJob Schedule: Full Time
The Social Work Care Coordinator is an office based social work position that will collaborate with patients, their families, physicians, local agencies and other home care clinicians to address a wide variety of patient needs. The Social Work Care Coordinator will be the primary support to the Home Care field clinicians and are a key component to the operations of the social work department.
Collaboration with the interdisciplinary team regarding patients that were identified for social work services. Assist agency staff with determining acuity level for timely services and assists with assigning and/or scheduling home visits.
Review the charts of new Social Work referrals and triage the referrals by level of acuity. Provide telephone interventions when deemed appropriate.
Assist MSW staff in maintaining compliance with DPH requirements for referral response; patient and MD phone calls, faxes and HIM documentation.
Confers with Agency staff regarding patient emergent needs and consults with Manager and LMSW/LCSW staff to assist in meeting these needs.
Assist field clinicians with managing their caseload; provides telephone interventions/discharges with patients or their family as appropriate. Telephone interventions include assessments of: psychosocial and emotional needs and stressors; basic needs; community resource, entitlement, insurance needs; complexity of needs; caregiver needs; patient/family’s ability to follow through.
Assist with case management needs including updating physicians, mailing applications, arranging transportation, completing referrals/applications for community resources, entitlements and benefits, etc.
Maintain thorough knowledge of Agency services, policies and procedures. Compile and maintain information on community resources, applications, entitlements and benefits; maintain online shared resource folder.
Assists with facilitating appropriate level of care including long/short-term skilled-nursing facilities, assisted living facilities, adult day care, etc. This can include:
Assessing payer sources and locating an appropriate facility
Completion of PASRR and Level of Care documents
Coordination with MD offices, patients/families and Agency care team staff.
In Addition, the position involves other duties such as:
Completes requests for data collection, chart audits and quarterly peer reviews.
Attends Agency and departmental education programs and meetings
Actively participates in the performance improvement process known as H3W
Performs other duties as assigned
Bachelor’s degree in Social Work from a school accredited by the Council on Social Work Education
BSW with 1+ years of health care experience in acute or community health settings
Knowledge, Skills and Ability Requirements
Knowledge of and ability to obtain community resources (town/state/federal programs and eligibility requirements)
Proven ability to work effectively independently and in a team environment.
Must be flexible with ambiguity and change processes.
Excellent written and verbal communication skills.
Strong organization skills and attention to detail.
Strong computer skills including Microsoft Office, Epic experience a plus
New clinicians will be required to complete:
Mental Health First Aid Certification
Movement Disorder Training