About the role
Overview
Provides assistance to patients/support systems and the multidisciplinary teams to identify, provide information, and facilitate access to tangible and supportive services related to patient health care needs.
Responsibilities
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Needs Assessment:
• In collaboration with care team, conduct evaluations of client needs through interviews and assessments
• In collaboration with care team identify barriers to accessing resources and develop strategies to address them -
Resource Coordination:
• Connect patients with appropriate services such as housing, healthcare, food assistance, transportation, and employment programs.
• Maintain an up-to-date knowledge of local community resources and eligibility criteria.
• Educate clients on available services and how to access them independently
• Identifies available transportation resources and collaborates with patient/support system for cost effective, safe transportation -
Advocacy:
• Advocate for patients to have knowledge to support access to resources and services they are entitled to
• Advocates/supports access for patients to skilled, acute or long-term care facilities -
Compliance and Documentation:
• Delivers important message from Medicare/Discharge Rights
• Collaborate to support completion of application process to obtain resources and with completion of Advanced Directive Care Planning
• Document case details in compliance with organizational policies. -
Collaboration:
• Work closely with social workers, counselors, and other professionals to support discharge planning and care transitions
• Attend inter-disciplinary rounds or unit huddles to strengthen relationships and improve resource access for patients. -
Administrative Tasks:
• Maintain accurate records and reports.
• Provide communication of resource availability for transitions of care to include unit phone support, e-mail communications, and direct patient meetings -
Performs other duties as required or assigned.
Qualifications
- Bachelor's degree in Social Work or Human Service field or the equivalent in education and experience required.
- Excellent interpersonal, communication, and organizational skills required.
Required Licensure/Certifications
- None
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