7 Habilitation Specialist jobs in Kennesaw

**Overview**
**Be inspired. Be rewarded. Belong. At Emory Healthcare.**
At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:
+ Comprehensive health benefits that start day 1
+ Student Loan Repayment Assistance & Reimbursement Programs
+ Family-focused benefits
+ Wellness incentives
+ Ongoing mentorship, development, and leadership programs.and more!
**Description**
The Social Work Care Manager (PRN) is responsible for patient care coordination from admission through discharge; ensuring smooth transitions of care as the patient is discharged from the hospital setting, ensuring and facilitating high quality clinical and cost outcomes, procuring and securing post-acute services, coordinating and advocating for patients and families with both internal and external stakeholders, and identifying and addressing potential barriers to care coordination/discharge planning in an effort to foster efficient care delivery and maximize reimbursement.
+ The SW CM (PRN) will begin the process of care coordination at the time of the patients admission by completing a thorough admission assessment and/or psychosocial assessment which will allow for a timely and accurate capture of information as well as foster the ability to begin working towards a discharge plan.
+ The Registry SW CM (PRN) is an integral part of the interdisciplinary care team who is required to attend rounds, care conferences, and/or care team meetings.
+ The Registry SW CM (PRN) will act as a representative of both the hospital care team and the patient/family in an effort to balance patient/family choice and projected care coordination needs with the ability to execute such services. The SW CM (PRN) will work with the hospital care team and the patient/family in order to plan and implement the best possible plan for the patient while taking various factors, limitations, and patient/family preference into consideration.
+ The SW CM (PRN) will identify post-acute services and will complete referrals to appropriate post-acute care providers in a timely manner, coordinating directly with the patient/family as well as the care team. Through continuous assessment and review, the SW CM (PRN) will apply critical thinking to ensure alignment and appropriateness of post acute services as the patient clinically progresses throughout their stay.
+ Ultimately, the SW CM (PRN) is responsible for ensuring the discharge plan is aligned to be executed with the patients medically cleared for discharge date as well as the projected length of stay as provided by the payor.
+ The SW CM (PRN)identifies and participates in the development of strategies to reduce unnecessary length of stay and/or resource consumption. The SW CM (PRN) escalates cases, as appropriate, to management, Physician Advisor, Complex Care team and/or Ethics committee. It is the role of the SW CM (PRN) to educate patients/families as well as the care team as it relates to post acute services, transitions of care, readmission mitigation, appropriate post-acute level of care choices and available resources.
+ The SW CM (PRN) provides supportive and therapeutic communication for patients, families and loved ones who are experiencing anxiety or stress due to illness, injury or physical limitations.
+ The SW CM responds to suspected violent, assault, abuse and/or neglect cases in accordance with social work professional ethics.
+ The SW CM (PRN) must communicate confidently, effectively, and therapeutically while being assertive and conveying an impression which reflects favorably upon the organization. In collaboration with Utilization Review, the SW CM (PRN) will initiate and facilitate discussions with the payors to act as an advocate on behalf of the patient and hospital in an effort to reduce non-covered, non-authorized, or denied services.
+ The SW CM (PRN) serves as a resource to the Physician, Interdisciplinary Care Team, and patient for the interpretation of external regulations and organizational policies and procedures as it pertains to Discharge Planning and Care Coordination.
+ The SW CM (PRN)will ensure compliance with all regulatory requirements as it relates to Government and Commercial Payors. The SW CM (PRN) will ensure compliance with all third party payers and federal and state regulatory agencies. The SW CM (PRN) will ensure proper use of Case Management Systems and workflows.MINIMUM QUALIFICATIONS:
+ Must have a Masters in Social Work from an accredited Institution.
+ 1 year recent healthcare experience preferred, experience in Acute Care setting preferred.
+ Must have working knowledge of software/Eemr applications. Must meet all quality and productivity expectations and successfully complete yearly competencies.
+ Must be able to work 4 shifts/mo.
**Additional Details**
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare's Human Resources at . Please note that one week's advance notice is preferred.
**Connect With Us!**
Connect with us for general consideration!
**Division** _Emory Univ Hospital_
**Campus Location** _Atlanta, GA, 30322_
**Campus Location** _US-GA-Atlanta_
**Department** _EUH Social Services_
**Job Type** _Regular Full-Time_
**Job Number** _148094_
**Job Category** _Hidden (17365)_
**Schedule** _8a-4:30p_
**Standard Hours** _4 Hours_
**Hourly Minimum** _USD $0.00/Hr._
**Hourly Midpoint** _USD $0.00/Hr._
Emory Healthcare is an Equal Employment Opportunity employer committed to providing equal opportunity in all of its employment practices and decisions. Emory Healthcare prohibits discrimination, harassment, and retaliation in employment based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, pregnancy, age (40 and over), disability, citizenship, genetic information, service in the uniformed services, veteran status or any other classification protected by applicable federal, state, or local law.

**Overview**
**Be inspired. Be rewarded. Belong. At Emory Healthcare.**
At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:
+ Comprehensive health benefits that start day 1
+ Student Loan Repayment Assistance & Reimbursement Programs
+ Family-focused benefits
+ Wellness incentives
+ Ongoing mentorship, development, and leadership programs.and more!
**Description**
The **Care Manager** is responsible for patient care coordination from admission through discharge; ensuring smooth transitions of care as the patient is discharged from the hospital setting, ensuring and facilitating high quality clinical and cost outcomes, procuring and securing post-acute services, coordinating and advocating for patients and families with both internal and external stakeholders, and identifying and addressing potential barriers to care coordination/discharge planning in an effort to foster efficient care delivery and maximize reimbursement.
The CM will begin the process of care coordination at the time of the patient's admission by completing a thorough admission assessment and/or psychosocial assessment which will allow for a timely and accurate capture of information as well as foster the ability to begin working towards a discharge plan.
The CM is an integral part of the interdisciplinary care team who is required to attend rounds, care conferences, and/or care team meetings. The CM will act as a representative of both the hospital care team and the patient/family in an effort to balance patient/family choice and projected care coordination needs with the ability to execute such services. The CM will work with the hospital care team and the patient/family in order to plan and implement the best possible plan for the patient while taking various factors, limitations, and patient/family preference into consideration. The CM will identify and recommend post-acute services and will complete referrals to appropriate post-acute care providers in a timely manner, coordinating directly with the patient/family as well as the care team. Through continuous assessment and review, the CM will apply critical thinking to ensure alignment and appropriateness of post -acute services as the patient clinically progresses throughout their stay. Ultimately, the CM is responsible for ensuring the discharge plan is aligned to be executed with the patient's medically cleared for discharge date as well as the projected length of stay as provided by the payor. The CM identifies and participates in the development of strategies to reduce unnecessary length of stay and/or resource consumption. The CM escalates cases, as appropriate, to management, Physician Advisor, Complex Care team and/or Ethics committee.
It is the role of the CM to educate patients/families as well as the care team as it relates to post acute services, transitions of care, readmission mitigation, appropriate post-acute level of care choices and available resources. The CM provides supportive and therapeutic communication for patients, families and loved ones who are experiencing anxiety or stress due to illness, injury or physical limitations.
The CM must communicate confidently, effectively, and therapeutically while being assertive and conveying an impression which reflects favorably upon the organization.
The CM will initiate and facilitate discussions with the payors in order to act as an advocate on behalf of the patient and hospital in an effort to reduce non-covered, non-authorized, or denied services. The CM will issue and administer notices of non-coverage and potential liability to patients in accordance with predetermined regulations, policies, and procedures. The CM serves as a resource to the Physician, Interdisciplinary Care Team, and patient for the interpretation of external regulations and organizational policies and procedures as it pertains to Discharge Planning and Care Coordination. The CM will ensure compliance with all regulatory requirements as it relates to Government and Commercial Payors. The CM will ensure compliance with all third party payers and federal and state regulatory agencies. The CM will ensure proper use of Case Management Systems and workflows.
**MINIMUM QUALIFICATIONS:**
+ Must have a Masters in Social Work from an accredited Institution.
+ 1 year recent healthcare experience preferred, experience in Acute Care setting preferred.
+ Must have working knowledge of software/Eemr applications. Must meet all quality and productivity expectations and successfully complete yearly competencies. Must be able to work 4 shifts/mo.
**JOIN OUR TEAM TODAY!** Emory Healthcare (EHC), part of Emory University (EUV), is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet® designated ambulatory practice. We are made up of 11 hospitals-4 Magnet® designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network,establishedin 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties.
**Additional Details**
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare's Human Resources at . Please note that one week's advance notice is preferred.
**Connect With Us!**
Connect with us for general consideration!
**Division** _Emory Univ Hospital_
**Campus Location** _Atlanta, GA, 30322_
**Campus Location** _US-GA-Atlanta_
**Department** _EUH Social Services_
**Job Type** _PRN / Registry_
**Job Number** _147102_
**Job Category** _Hidden (17365)_
**Schedule** _8a-4:30p_
**Standard Hours** _4 Hours_
**Hourly Minimum** _USD $0.00/Hr._
**Hourly Midpoint** _USD $0.00/Hr._
Emory Healthcare is an Equal Employment Opportunity employer committed to providing equal opportunity in all of its employment practices and decisions. Emory Healthcare prohibits discrimination, harassment, and retaliation in employment based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, pregnancy, age (40 and over), disability, citizenship, genetic information, service in the uniformed services, veteran status or any other classification protected by applicable federal, state, or local law.

**Overview**
**Where you matter as much as the work you** **do**
Join **Emory Healthcare (EHC)** ifyou'relooking for an opportunity withone of the nation's leading Atlanta hospitals in cardiology and heart surgery, cancer, neurology,and more! **EHC** is where those around you are dedicated to the power of teamwork, fostering an environment where you can learn, grow, and innovate with similarly passionate professionals. Work with us to improve the quality of life throughout Georgia through partnerships with the U.S. Centers for Disease Control andPrevention, GeorgiaInstitute of Technology, and other organizations and make a bigger, greater impact than you ever thought possible.
**Description**
The **Social Work Care Manager (PRN)** is responsible for patient care coordination from admission through discharge; ensuring smooth transitions of care as the patient is discharged from the hospital setting, ensuring and facilitating high quality clinical and cost outcomes, procuring and securing post-acute services, coordinating and advocating for patients and families with both internal and external stakeholders, and identifying and addressing potential barriers to care coordination/discharge planning in an effort to foster efficient care delivery and maximize reimbursement.
The SW CM (PRN) will begin the process of care coordination at the time of the patient's admission by completing a thorough admission assessment and/or psychosocial assessment which will allow for a timely and accurate capture of information as well as foster the ability to begin working towards a discharge plan.
The Registry SW CM (PRN) is an integral part of the interdisciplinary care team who is required to attend rounds, care conferences, and/or care team meetings. The Registry SW CM (PRN) will act as a representative of both the hospital care team and the patient/family in an effort to balance patient/family choice and projected care coordination needs with the ability to execute such services. The SW CM (PRN) will work with the hospital care team and the patient/family in order to plan and implement the best possible plan for the patient while taking various factors, limitations, and patient/family preference into consideration. The SW CM (PRN) will identify post-acute services and will complete referrals to appropriate post-acute care providers in a timely manner, coordinating directly with the patient/family as well as the care team. Through continuous assessment and review, the SW CM (PRN) will apply critical thinking to ensure alignment and appropriateness of post -acute services as the patient clinically progresses throughout their stay. Ultimately, the SW CM (PRN) is responsible for ensuring the discharge plan is aligned to be executed with the patient's medically cleared for discharge date as well as the projected length of stay as provided by the payor. The SW CM (PRN)identifies and participates in the development of strategies to reduce unnecessary length of stay and/or resource consumption. The SW CM (PRN) escalates cases, as appropriate, to management, Physician Advisor, Complex Care team and/or Ethics committee.
It is the role of the SW CM (PRN) to educate patients/families as well as the care team as it relates to post acute services, transitions of care, readmission mitigation, appropriate post-acute level of care choices and available resources. The SW CM (PRN) provides supportive and therapeutic communication for patients, families and loved ones who are experiencing anxiety or stress due to illness, injury or physical limitations. The SW CM responds to suspected violent, assault, abuse and/or neglect cases in accordance with social work professional ethics.
The SW CM (PRN) must communicate confidently, effectively, and therapeutically while being assertive and conveying an impression which reflects favorably upon the organization.
In collaboration with Utilization Review, the SW CM (PRN) will initiate and facilitate discussions with the payors to act as an advocate on behalf of the patient and hospital in an effort to reduce non-covered, non-authorized, or denied services. The SW CM (PRN) serves as a resource to the Physician, Interdisciplinary Care Team, and patient for the interpretation of external regulations and organizational policies and procedures as it pertains to Discharge Planning and Care Coordination. The SW CM (PRN)will ensure compliance with all regulatory requirements as it relates to Government and Commercial Payors. The SW CM (PRN) will ensure compliance with all third party payers and federal and state regulatory agencies. The SW CM (PRN) will ensure proper use of Case Management Systems and workflows.
**MINIMUM QUALIFICATIONS:**
+ Must have a Masters in Social Work from an accredited Institution. 1 year recent healthcare experience preferred, experience in Acute Care setting preferred.
+ Must have working knowledge of software/Eemr applications.
+ Must meet all quality and productivity expectations and successfully complete yearly competencies.
+ Must be able to work 4 shifts/month.
**JOIN OUR TEAM TODAY!** Emory Healthcare (EHC), part of Emory University (EUV), is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet® designated ambulatory practice. We are made up of 11 hospitals-4 Magnet® designated, the Emory Clinic, and more than 425 provider locations. The Emory Healthcare Network,establishedin 2011, is the largest clinically integrated network in Georgia, with more than 3,450 physicians concentrating in 70 different subspecialties.
**Additional Details**
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare's Human Resources at . Please note that one week's advance notice is preferred.
**Connect With Us!**
Connect with us for general consideration!
**Division** _Emory Univ Hospital_
**Campus Location** _Atlanta, GA, 30322_
**Campus Location** _US-GA-Atlanta_
**Department** _EUH Social Services_
**Job Type** _PRN / Registry_
**Job Number** _144972_
**Job Category** _Hidden (17365)_
**Schedule** _8a-4:30p_
**Standard Hours** _4 Hours_
**Hourly Minimum** _USD $0.00/Hr._
**Hourly Midpoint** _USD $0.00/Hr._
Emory Healthcare is an Equal Employment Opportunity employer committed to providing equal opportunity in all of its employment practices and decisions. Emory Healthcare prohibits discrimination, harassment, and retaliation in employment based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, pregnancy, age (40 and over), disability, citizenship, genetic information, service in the uniformed services, veteran status or any other classification protected by applicable federal, state, or local law.

Clinical Social Worker Health Care Facility Surveyor - Georgia (#1247)

• Paid holidays
• Employee discounts
• Employee retirement plan (401k)
• Company-paid life insurance
• CMS’s Long-Term Care Basic Training and SMQT certification are required

Impact Recruiting Solutions is currently seeking a Clinical Social Worker Health Care Facility Surveyor to fill an opening with a Quality Improvement Consulting Company and will work in a technically exciting environment supporting internal and external customers nationwide.

Requirements

• Must have a Master's degree in Social Work
• Must have successfully completed CMS’s Long-Term Care Basic Training and passed the Surveyor Minimum Qualifications Test (SMQT).
• Must have at least two (2) years of recent experience working as a surveyor accrediting or certifying facilities that serve the residents of long-term care facilities.
• Must maintain current licensure to practice as an LCSW
• Demonstrated history of independent decision-making skills to direct and effectively manage the survey process.
• Ability to set priorities independently and collectively in performing survey tasks.
• Ability to openly discuss conflicts/controversy, and to seek assistance when appropriate to make decisions and resolve conflicts.
• U.S. Citizenship is required for this position
• Ability to travel up to 75% of the time on a regular basis is required

Benefits

• The salary for this position is $72,000 - $80,000 / yr
• This is a Full-time position (Monday - Friday)
• Flexible paid vacation days
• Paid holidays
• Company-issued and company-paid Amex card for travel
• All travel expenses paid directly by the company
• Airline and hotel points accumulate for employee's personal use
• Employee discounts
• Employee retirement plan (401k) with a generous match and immediate vesting
• Company-paid tax-free Health Savings Account (HSA)
• Health insurance
• Dental insurance
• Vision insurance
• Company-paid life insurance
• Company-paid disability insurance
• Extensive training opportunity
• Predictable work schedule

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Job Summary:
The Care Coordination Social Worker Sr. (SW Sr) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's psychosocial and resource needs. In conjunction with the patient and physician, the SW Sr will assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care. Overall, the role integrates and coordinates the patients transitional care plan into their individualized discharge plans based on needs and resources available.Specific functions within this role include:Responsible for providing psychosocial assessments for patients to include timely and appropriate planning to advance the discharge plan.Assists in relaying information about community-based service offerings (e.g.-indigent care referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.Serves as a specialist on issues related to psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.Will partner and offer feedback to the RN Care Coordinator concerning complex social determinants of health issues, situational dynamics, and social needs.Will participate in orientation and precepting of new social work hires (as needed). The SW Sr will mentor other social workers in case reviews and discussion of difficult situations, to include, but not limited to assessing suicidal ideation, bereavement risk, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios. May have other duties assigned.Core Responsibilities and Essential Functions:
Complex Disposition Planning* Implements discharge planning and provides resource information in a timely and efficient manner for complex patients.* Identifies and documents barriers for timely disposition.* Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.* Responds to referrals for patient assistance from RN Care Coordinators, physicians and the care team.* Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.* Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.* Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.* Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning.* Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.* Allows for any cultural or religious beliefs in providing service and continuity of care.Assessment* Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.* Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.* Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans.Documentation* Initial psychosocial /functional assessment completed and documented in medical record.* Ensure all records are up-to-date and documentation is understandable.* Ensure timely and accurate documentation of progress notes and interactions with patient/family.* Accounts for and indicates all services arranged/delivered in Electronic Health Record.* Track avoidable days and report trends that lead to undesired outcomes.Precepting/Mentoring* Assist leadership with precepting new hires when needed.* Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.* Serves as a preceptor and/or mentor for student internsProfessional Development and Initiative* Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.* Supports departmental- based goals which contribute to the success of the organization.* Participates in the development of protocols, procedures and performance improvement as indicated* to optimize patient outcomes.Performs other duties as assignedComplies with all Wellstar Health System policies, standards of work, and code of conduct.Required Minimum Education:
Master's Degree degree in Social Work from an accredited college or university Required andLMSW in State of GA (can be waived if have LCSW) Required andACM or CCM PreferredRequired Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Lic Clinical Social Worker GA or Lic Master Social Worker GA
• Basic Life Support or BLS - Instructor
• Certified Case Manager-Preferred or Accredited Case Manager-Preferred

Additional License(s) and Certification(s):
Required Minimum Experience:
Minimum 2 years of experience in healthcare in the acute care setting, related field or skilled care environment or community. Required andA background in medical social work in an acute care setting PreferredRequired Minimum Skills:
Excellent written and verbal communication skill.Must possess maturity, self-confidence, objectivity, and positive attitude.Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environmentStrong assessment, interview, organizational and problem-solving skills.Knowledge regarding local, state and federal regulations required.Knowledge of community and state-wide resources and programs.Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

Join us and discover the support to do more meaningful work-and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Job Summary:

Wellstar North Fulton Hospital has an opportunity for a Care Coordinator Complex Case Social Worker. Full-Time Day shift

The SW Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available.
Specific functions within this role include:
Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan.
Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team.
Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs.
Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentor other care coordinators in case reviews and discussion of difficult situations, to include, but not limited to patient legal status, court regulations, financial options, suicidal ideation, grief and bereavement, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios.
May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient population.
Supports leaders in negotiating agreements with community agencies and facilities.
May have other duties assigned as it relates to hospital complex patient population

Core Responsibilities and Essential Functions:

Complex Disposition Planning
* a. Implements discharge planning and provides resource information in a timely and efficient manner for complex patients.
b. Identifies and documents barriers for timely disposition.
c. Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
d. Responds to referrals for patient assistance from RN physicians and the care team.
e. Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
f. Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
g. Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum.
h. Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning.
i. Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
j. Arranges and facilitates family meetings when needed.
k. Allows for any cultural or religious beliefs in providing service and continuity of care.
Assessment
* a. Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.
b. Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
c. Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans.
3. Documentation
a. Initial psychosocial /functional assessment completed and documented in medical record.
b. Ensure all records are up-to-date and documentation is understandable.
c. Ensure timely and accurate documentation of progress notes and interactions with patient/family.
d. Accounts for and indicates all services arranged/delivered in Electronic Health Record.
e. Enter avoidable days, when applicable, in the Electronic Health Record.
Professional Development and Initiative
*a. Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
b. Supports departmental- based goals which contribute to the success of the organization.
c. Participates in the development of protocols, procedures and performance improvement as indicated
to optimize patient outcomes.
4. Precepting/Mentoring
a. Assist leadership with precepting new hires when needed.
b. Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.
c. Serves as a preceptor and/or mentor for student interns
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

Master's Degree Masters degree in Social Work from an accredited college or university. Required or

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Lic Master Social Worker GA or Lic Clinical Social Worker GA
• Basic Life Support or BLS - Instructor
• Accredited Case Manager-Preferred or Certified Case Manager-Preferred

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environments. Required and
Minimum 2 years in care coordination in the acute care setting. Required

Required Minimum Skills:

Excellent written and verbal communication skill.
Must possess maturity, self-confidence, objectivity, and positive attitude.
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment
Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required.
Knowledge of community and state-wide resources and programs.
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

Join us and discover the support to do more meaningful work-and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.