Acute Care Navigator - Social Worker - Discharge Planning - Full time

Overview

Job Summary: 

Coordinates and supports the providers and multidisciplinary team in facilitating patient care, providing ongoing care management services during an acute-care admission as well as continued follow up with the objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care. Provides utilization management, clinical documentation integrity, discharge planning and post-acute care needs assessment and acts as a liaison for utilization management and clinical documentation improvement. Responsible for designated unit-based patient cases and plans effectively in order to meet patient needs, manage the length of stay via monitoring and coordination of care pathways and promote efficient utilization of resources.

Essential Functions:

Participates in rounds on the patient care unit with the attending physician and other members of the health care team; coordinates communication to assure collaboration and consistency in moving the patient’s care to estimated date of discharge.

Assesses patients to determine their discharge planning and/or post-acute transition needs. Develops the discharge plan and works with the physician to implement the plan utilizing internal and external resources to ensure a safe discharge or transition to alternate level of care. Plan will address the following: assessment of patient's physical, functional, social and psychological status; assessment of cultural and language needs; assessment of caregiver resources and available benefits.

Assigns the appropriate care pathway based on the clinical feedback from the physician and the diagnosis-DRG. Ensures coordination of services among the patient's physicians, specialists, community agencies and vendors. 

Assesses progress toward goals and identifies barriers to meeting goals. Prepares and maintains appropriate documentation of patient care and progress within the designated systems.

Education, Experience, and Training: 

Must have Bachelor’s degree in Social Work.  Master’s degree is preferred. 

Discharge Planning experience in a healthcare setting.

Three (3) years of recent experience in acute care, home health, long term care, or disease/care management.   

Experience with IT solutions such as electronic health record, learning management or disease/care management systems a plus.

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