Social WorkerDoctors Medical Center of Modesto
Modesto, CA30 days ago
This individual’s responsibility will include the following activities: a) care coordination, b) transition planning assessment and reassessment which may include complex psycho-social assessment and intervention, c) implementation or oversight of implementation of the transition/discharge plan, d) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, e) care coordination, f) implementation or oversight of implementation of the transition plan, g) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, h) making appropriate referrals to other departments, i ) communicating with patients and families about the plan of care, j) collaborating with physicians, office staff and ancillary departments, k) assuring patient education is completed to support post-acute needs ,l) timely complete and concise documentation in Case Management system, m ) maintenance of accurate patient demographic and insurance information, n) precepts new staff members and acts as a resource to all staff, o) facilitates TEMPO as needed, p) participates in department quality improvement initiatives, and q) other duties as assigned. The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination.