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Summary:

Responsible for partnering with the physician and multidisciplinary team in coordinating patient care with the underlying objective of enhancing quality and cost effective care.  Acts as a resource and patient advocate to facilitate a safe transition across the continuum.

Position Responsibilities:

Care Coordination – completes appropriate assessments and plans effectively to meet patient needs, monitors the length of stay and promotes efficient utilization of resources.  Acts as a clinical expert and maintains ongoing knowledge of clinical practice guidelines.  Engages the physician and builds seamless continuity of care and is the physicians single consistent resource.  Problem resolution, patient/family communication. Helps identify factors impeding patient progression, resolves, escalates and documents as appropriate.  Refers appropriate cases for Social Work intervention.

Documentation – Appropriate and complete documentation of individual plan of care in EMR and case management documentation system.

Metrics- Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization.

Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities.

Compliance – understands and applies applicable federal and state requirement. Identify and reports compliance issues as appropriate.

Position Qualifications Required:

Required Experience:

Minimum 3 years clinical nursing (RN) experience or Social Work

Minimum of 1 year Case Management or other interdisciplinary experience including Homecare Coordination in an Acute Care setting; understanding of Medicare, Medicaid, managed care and discharge planning. (3-5 years preferred)

Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution.

Required Education:

RN or Masters prepared Social Worker

Training / Certification / Licensure:

RN or LSW required;  LCSW considered