Purpose : Interacts with patients, family members, healthcare professionals, and community and state agencies to ensure the patient's progress in the acute episode of care through post discharge is quality driven, while being efficient and cost effective.
Serves as a liaison between the hospital and community agencies or facilities for the exchange of clinical and referral information.
Identifies high risk patients from a psychosocial / financial perspective, through screening mechanisms, and assesses the needs of patients and families and provides information, support, counseling, case facilitation, and timely, accurate referrals to appropriate resources.
Ensures that a transition plan for ongoing management or resolution of issues is in place at the time that the patient is clinically ready to leave the acute care environment.
Performs patient home visits.
Report To : Director, Care Coordination
Supervisory Responsibility : Guidance : The job requires the provision of occasional guidance and training to others. The job does not have formal or official supervisory responsibilities.
Materials Responsibility : Moderate : Work requires moderate responsibility for material resources. Examples of resources could include operating budgets for a work unit or department, specialized equipment, costly or unusual materials or supplies, large amounts of cash or other material assets.
The employee has a moderate amount of control over these resources. The cost of errors might result in moderate damage, waste or financial loss.
The difficulty, variety and depth of problems associated with these material resources is moderately complex.
Key Relationship : Co-workers / Health System Employees, Outside Agencies / Other Health Care Providers, Physicians / Medical Office Staff, Students / Interns / Residents / Outside Instructors, Patients, Families, and Significant Others, Vendors / Clients, Third Party Payors / Insurance Companies
POSITION SPECIFICATION
Education : Master's Degree
Field Of Study : Social Work
Special Training : Training Preferred :
Training Preferred :
Licensure / Registration : Licensure in Iowa or Illinois required at time of hire. License in the second state (Iowa or Illinois) required within 6 months of hire.
Experience : More than 2 years experience required.
Interpersonal Skills : Interaction is with a variety of people inside or outside the organization. Communications are often difficult or stressful in nature.
Contact with others involves complex, detailed and often sensitive topics. The job requires a high degree of interpersonal skills to deal with a range of complicated problem situations.
Interactions involve gaining the agreement of others.
CANDIDATE DETAILS
2+ to 5 years experience
Seniority Level - Other
Management Experience Required - No
Minimum Education - Master's Degree
Willingness to Travel - Occasionally
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