Patient Care Coordinator

2 months ago

Bethlehem, Pennsylvania, United States St. Luke's University Health Network Full time

Job Summary:


The Social Worker Care Manager will be responsible for coordinating the complex discharge planning needs of patients, as well as providing supportive counseling, psycho-social assessment and interventions for designated patient populations across the continuum of care.



Key Responsibilities:



  • Develop a discharge plan that addresses the psycho-social needs to meet desired goals for the next step in the continuum of care for patients.
  • Collaborate with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient's needs and goals.
  • Work as a team with other members of care management, including but not limited to: RN care managers, assistants, coordinators, utilization management staff, and director.
  • Facilitate communication among all treatment team members.
  • Manage length of stay by proactively identifying and mitigating issues and barriers to care and a successful discharge plan.
  • Update the care team, patient/family as to the status of the discharge plans. Re-evaluate and revise the discharge plan as additional information is acquired.
  • Proactively consider options such as palliative care, homecare and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of readmissions.
  • Issue applicable state/federal regulatory notices as applicable ie.) Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle Payment Care Initiative (BPCI) notification.
  • Monitor risk assessment using available tools and implement discharge interventions accordingly.
  • Actively address and monitor resource utilization and document delays as appropriate.
  • Identify patients with an unplanned readmission and complete root cause analysis.
  • Coordinate utilization of patient and community resources to facilitate achievement of a safe and effective discharge plan and accomplishment of goals as well as minimizing risk of readmission.
  • Collaborate with Outpatient Care Managers to identify patients for handover and post discharge follow up.
  • Provide supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement. Facilitate the decision making process in complex cases.
  • Facilitate resolution of issues surrounding patient care in a compassionate manner, utilizing team meetings as appropriate.
  • Act as resource to the staff for regulatory issues regarding discharge-planning and psychosocial processes.
  • Use electronic systems to accurately document care manager functions.


Requirements:



  • MSW or equivalent from an accredited school of social work. Current NJ SW license if working at St. Luke's Warren Campus.
  • May hire per diem BSW's currently in school within 6 months of completing MSW. If primary coverage area is OB, membership in the National Organization of Perinatal Social Workers is required.
  • At least two years of experience as a Social Worker in an acute hospital setting.
  • Strong critical thinking skills.
  • Ability to maintain collaborative and effective working relationships.
  • Able to assert needs to patients, families, physicians, and other members of the interdisciplinary team while maintaining established rapport and relationships.
  • Knowledge of medical terminology required.
  • Ability to communicate both verbally and in written forms.
  • Basic computer skills required.

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