The role of the Care Coordination Social Worker Ii is to assist the care team by providing leadership in supporting and facilitating coordinated care delivery to patients, proactively identifying and eliminating barriers to discharge, collaborating with the care team to ensure planning for appropriate post-acute care plan and back-up plan. Specific job functions will vary based on assigned area but would include items such as:
- Coordinate services for all patients assigned prioritizing moderate and high risk patients with serious, complex or chronic health problems or with psychosocial issues.
- Provide advocacy, information and referral services to patients and families to address their psychosocial needs.
- Assists all patients through the healthcare system by acting as a patient advocate and navigator.
- Promotes clear communication with the care coordination team and caregivers, ensuring awareness regarding patient care coordination plan related to transitions of care.
- Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to organization goals for length of stay, readmissions and patient experience.
- Masters of Social Work or related field required
- Current Ohio Social Work license required.
- Clinical experience in health care setting
- Awareness of developmental needs over the age span of infant to elder required.
- Ability to work well in multidisciplinary and independent settings and communicate well (verbal and written)
- Ability to coordinate work effectively with other hospital disciplines.
- Ability to recognize and understand the dynamics of individuals from diverse populations.
- Ability to solve problems through the analysis of information.