About the role
Job Summary Provides leadership in post-acute care coordination and psychosocial support to patients and families. Acts as a resource for appropriate utilization of acute care services and length of stay. Engages in departmental operations and improvement projects.
Responsibilities include gathering comprehensive information to identify patient needs, developing psychosocial assessments and intervention plans, and collaborating with interdisciplinary teams and community resources. Offers crisis intervention and counseling to support emotional and adjustment needs.
Documents assessments, interventions, and outcomes per policies. Coordinates discharge planning, communicates with payors, and educates the care team on bed utilization and care levels. Organizes discharge rounds and maintains effective communication to facilitate timely and appropriate patient care.
Demonstrates organizational skills, adherence to social work ethics, and participation in staff development and quality improvement initiatives. Engages in peer review, committees, and promotes effective communication within the team.
Requirements include a Bachelor’s in Social Work, LBSW license in MD, and a minimum of 3 years of experience (5+ preferred). The role demands strong leadership, interpersonal skills, and knowledge of community resources to enhance patient outcomes.
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