Job Description

Overview

You Matter Here!

Heywood Healthcare values our employees! We offer competitive wages great benefits and generous earned time off. Come work where you will matter!

Hours: 40-Hours Days No holidays

$52100 - $83200

Disclaimer:

We are committed to equitable and transparent compensation practices. The salary range for this position reflects our good-faith estimate of base pay at the time of posting. Final compensation will be determined based on a variety of factors including relevant experience skills qualifications and internal equity. We regularly review our compensation structures to ensure fairness and consistency across our organization.

Responsibilities

Essential Functions

• Care Transitions & Coordination: Reports directly to the Manager of Care Transitions and Indirectly reports to Unit Manager and Practice Leader.

• Keeps department leaders abreast of any issues trends identified and/or needs weekly and/or more frequently if needed.

• Demonstrates professionalism and teamwork. Works collaboratively with unit team and responds timely efficiently and respectfully. Covers for co-workers during planned and un-planned absences and as requested by leadership.

• Provides service to community at large through the provision of service to Walk-In and telephone inquires as assigned by leader and/or designee as needed.

• Conducts comprehensive psychosocial assessments for patients and families. Identifies social emotional financial and environmental barriers to care. Assesses mental health concerns coping ability and support systems.

• Completes the Assessment fully clearly concisely and within 24-48 working hours of being assigned the case.

• Completes documentation using the documentation standards noted by department policies and procedures as well as state and federal regulations.

• Completes clear and concise documentation noting patient and family participation multidisciplinary involvement and other planning information as required by the department as well as state and federal regulation agencies.

• Discharge Planning: Communication: builds rapport and responds to needs of physician healthcare team members 3rd party payers referral sources and vendors to enhance internal and external customer service satisfaction.

• Conducts High Risk Screening on all patients on assigned units for potential needs as per policy. Completes HRSN Screen within 24 working hours of case assignment.

• Effectively supports the discharge planning process by ensuring services and placements are appropriate within the continuum of care. Completes required documentation accurately and in a timely manner maintaining compliance with regulatory standards.

• Demonstrates strong performance in educating patients on their rights consistently providing accurate timely and comprehensive information. Ensures patients understand applicable processes and resources supporting informed decision-making and maintaining compliance with regulatory and organizational standards.
• Provides short-term counseling to patients and families coping with illness trauma grief or adjustment challenges. Supports patients dealing with chronic illness terminal diagnoses or major life changes.
• Effectively provides patients and families with clear relevant education regarding the care plan tailored to individual needs. Collaborates closely with the multidisciplinary team to ensure coordinated patient-centered care and support continuity across settings.
• Responds to psychosocial crises including: Domestic violence abuse or neglect concerns suicidal ideation and family conflict.
• Advocates for patients rights dignity and access to appropriate care. Addresses barriers related to social determinants of health.
• Conducts post discharge follow up on High Risk patients in an attempt to reduce re-hospitalization.
• The Discharge Planning Process:
  Completes discharge planning assessments timely efficiently and completely following regulatory standards and departmental policies assuring appropriate patient flow.
  Appropriately levels patient for home discharge with or without services or to another type of facility such as a SNF Acute Rehab etc. Develops coordinates and implements discharge plan on cases assigned with patient and/or family/so caregiver. Identifying patient preference and selection choice for HHA/SNF placements having patient preference form checked off and signed/dates by patient and/or so. When plan is in place notify provider establish and determine anticipated readiness for discharge keeping patient/family/so informed and documenting such in the EMR. Closes case out using appropriate forms for transition of care communication timely and efficiently.
  Collaborates with the team to assist the Multidisciplinary Team in providing discharge planning activities to assist in expediting a patients discharge as part of the care transitions process.
  Completes case closure using appropriate transitions-of-care communication forms in a timely and efficient manner.
  Maintains current knowledge and proficiency in discharge planning processes and best practices.

• Multidisciplinary Team Rounds -participates in discharge planning rounds daily. Works collaboratively with multidisciplinary team to determine each patients needs concurrently including post-acute care when needed; addresses LOS issues addresses potential needs resources referrals for other disciplines and a positive professional manner.

• Utilization Management

  Works collaboratively with the assigned RN Care Coordinator to ensure appropriate and timely clinical information is available to support the utilization review process with insurance payers. Participates in weekly utilization review meetings to address extended lengths of stay identify additional information needed for concurrent reviews and discuss the status of discharge planning. Initiates discharge planning at the time of admission to help ensure appropriate services and supports are arranged promoting an effective and successful transition of care.

• Quality & Statistical Data :

  Participates in performance improvement activities and other projects as assigned by leader.

  Consistently completes statistical records for each closed case accurately capturing hours contacts and services provided. Maintains timely and thorough documentation to support departmental reporting and data integrity.

  Cases are expected to have a closing note using the CM/SW Discharge/Closing note recording services provided hours invested on disposition day of discharge or next working day.

Statement of Other Duties

This document describes the major duties and responsibilities for this job and is not intended to be a complete list of all tasks and functions. It should be understood therefore that employees may be asked to perform job-related duties beyond those explicitly described.

Functional Demands

Physical Requirements:

Exerts up to 20 pounds of force occasionally and/or up to 10 pounds of force frequently and/or a negligible amount of force constantly to move objects. Frequently reaches (extending hands and arms in any direction) and handles (seizing holding grasping turning or working with hands).

Organizational Expectations

Behavioral Attributes:

The following behavioral attributes are required: achievement motivation concern for order flexibility initiative self-confidence customer service oriented interpersonal effectiveness teamwork analytical thinking and information seeking.

Qualifications

Job Requirements

Minimum Education

• Associates Degree required Bachelors Degreepreferred in SW or related field

Minimum Work Experience

• Minimum one to three years experience in a hospital setting Skilled Nursing Facility or community social/health agency.

Minimum Licenses and Certifications

• MAState licensure required LCSW LSW or LSWA.

Required Skills

• Ability to work independently and with a team
• Excellent verbal and written communication skills required
• Computer experience for data collection report writing and quality monitoring
• Ability to work with community agencies to mobilizeresources requited
• Demonstrates flexibility and adaptability to change
• Demonstrates ability to clearly assess behavioral health needs as well as other psychosocial aspects of patient care including but not limited to the health-related social needs of our patients; good knowledge of assessment counseling and crisis intervention techniques.

Required Experience:

IC

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