Social Service Care Coordinator

The Social Service Care Coordinator monitors, evaluates and coordinates a safe transition to home.  Coordinates the services to meet patients’ health needs to ensure cost-effective, quality outcomes in a fast paced short term rehabilitation and long term care environment.  Completes all necessary paperwork to meet State and Federal regulatory standards.  This position provides social and emotional support to residents during their stay in the facility.

• Manages the care coordination process for each patient from admission to discharge.
• Swiftly acclimate patient and family to facility and establishes positive relationship with excellent Customer Service.
• Plans and arranges for a successful patient safe transition to home thus reducing risk for readmission.
• Competent and at ease with discussing medical conditions.  Communication with physicians, surgeons, therapists, patients, families, medical team coworkers, hospital discharge planners, home health admissions expected.
• Accountable for leading and facilitating the weekly IDT (interdisciplinary team) utilization review meeting.  Leads the discussion in strategizing discharge dates/times.
• Assesses and communicates to ensure care team and patient, patient family aware of goals & plans for patient.
• Completes a social service assessment upon admission and completes social service MDS sections with CAAs. Able to create an effective Care Plan for the patient.
• Assists and directs patients & their families to appropriate resources when personal issues develop.
• Guides patients/family designee to apply for financial assistance as needed ie: Medicaid, VA benefits, etc.
• Cross market within the organization and the understanding of all the services Community First Solutions has to offer the patient.
• All other duties as assigned and/or appropriate to the position.

Education:  Associate’s Degree required; Bachelor’s Degree preferred

Licenses or other required certifications: LPN or LSW

Experience:  Minimum of two (2) years professional experience in the health related field as a social worker or nurse; experience in case management/discharge planning with a hospital or skilled nursing, preferred

Specialized knowledge, skills, or abilities:  

• Demonstrate familiarity with hospital and skilled nursing admission and discharge processes
• Understand healthcare operations and legal guidelines
• Excellent verbal, written, interpersonal and organizational skills
• Excellent organization and time management skills
• Excellent attention to detail
• Incumbent should demonstrate:
• Strong customer service orientation
• Friendly, approachable, calm demeanor
• Ability to maintain a flexible work schedule, including some evenings and weekends
• Ability to collaborate and develop strong relationships with other health care providers, suppliers, coworkers, and customers
• Ability to maintain patient confidentiality
• Ability to work in an environment of changing demands and frequent interruptions
• Intermediate experience with Microsoft Office products (Word, Excel, and Outlook) required and knowledge of Point Click Care preferred
• Must have a valid driver’s license