In collaboration with the Admissions Team, assures coordination of patient admissions, referrals, transfers and discharges.
Maintains focused attention to the goal of seamless and smooth transition for all parties involved in the provision of continuity of care between discharge to community placement and internal transfer to a different level of care.
In collaboration with the interdisciplinary team, addresses internal patient transfer issues with patient, families and others, attending to resident rights and effective use of resources.
Using a collaboration model, plans, organizes and directs activities of social workers and case managers to assure applicable regulations of HFS 132/HFS 83, standards and practices are met.
Utilizes and coaches staff in a proactive manner with attention to resident/family actual and potential concerns related to advance directives, emotional adjustments resulting from life changes, relocation stress and conflicts.
Advocates for the resident/family by assuring all applicable rights are observed and concerns are addressed in a timely manner.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Coordination of admissions, referrals, transfers and discharges
Arranges for complete and accurate processing of all admission packet information for all patients being admitted.
Coordinates admissions/discharges/transfers to coincide with appropriate bed and staff availability.
Assures all parties involved are aware of and understand expectations for admission/transfer/discharge of all patients.
Establishes familiarity with contractual arrangements and terms of HMOs and their relationship to admission of patients.
Assurance of seamless transitions and discharges:
Monitors and addresses issues raised by quality assurance mechanisms of follow-up calls and satisfaction surveys of discharged residents.
Arranges for or directs resolutions for potential/actual roommate/room conflict situations.
Proactively addresses actual or potential resident issues with advance directives, emotional adjustment to transfer, re-location, life changes and conflicts:
Assures a current and accurate listing is kept of advance directive status for all residents, including notations of specific issues related to those documents and their activation.
Assures continuous dialog leading to therapeutic relationships is kept with identified family members.
Assures social workers maintain an ongoing and collaborative working relationship with the interdisciplinary team.
Schedules, conducts and/or directs meetings to address resident/family care concerns, keeping administrator informed of potential risk situations.
Directly supervises social workers and support staff. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
Bachelor’s degree in social work, sociology, or psychology; meet the national association of social worker standards of membership; and have one year of social service experience in a health care setting; or a Master’s degree in social work from a graduate school of social work accredited by the council on social work education.
Ability to read and write English at a technical level equivalent to college level study in medicine and applied health sciences. Ability to read, analyze and interpret common scientific and technical journals, financial reports and legal documents. Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public. Verbal communication skills and command of English language sufficient to carry on conversations with licensed health care professionals including physicians. Knowledge of medical terminology, clinical documentation practices and common medical abbreviations to read patient records accurately. Knowledge of pharmacology to interpret medical regimes and medication orders of common usage. Writing skills sufficient to compose grammatically correct letters of a medical nature, written assessments of patient conditions and business letters. Ability to respond to common inquiries or complaints from customers, regulatory agencies or members of the business community.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference and volume. Ability to apply concepts of basic algebra and geometry.
Ability to define problems, collect data, establish facts and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
COMPUTER SKILLS (Prior To Hire)
Power Point: Beginner
COMPUTER SKILLS (After Orientation)
Power Point: Intermediate
Ability to utilize basic office equipment including a pager, computer keyboard, word-processing software, spreadsheet software, telephone, fax machine and copy machine with common training. Flexibility in schedule to work varying hours plus occasional weekend hours. Job requires direct patient contact to conduct assessments and to interview patients, in some instances under isolation conditions and situations of medical distress.
PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; sit; use hands to finger, handle or feel; and reach with hands and arms. The employee is occasionally required to climb or balance; stoop, kneel, crouch or crawl; and taste or smell. The employee must frequently lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, depth perception and ability to adjust focus.
WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.