Social Worker - Discharge Planning
Social Worker - Discharge Planning
Posted on :
10-04-2025
Employer Active
1 Vacancy
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Monthly Salary
Not Disclosed
Salary Not Disclosed
Vacancy
1 Vacancy
Posted on :
10-04-2025
Job Description
Summary
Job Summary
Oversees care management and coordination of activities for patients of the healthcare system. Develops and monitors care management coordination processes and support of patients for multidisciplinary teams. Identifies high acuity patient population high utilizers and high readmission risk patients.
Job Responsibilities
- Works with all clinical teams as a resource on care management of all patients of the healthcare system to ensure care completion in and out of the hospital setting.
- Involves the patients in activities to improve their health (patient engagement); educates patients about self management tasks they can undertake to gain greater control of their health status.
- Manages assigned panel of chronic care high acuity and readmission risk patients.
- Develops relationship with patient as an integral member of the team.
- Provides followup contact with patient as indicated to ensure compliance with recommendations medications lab xray specialist visits Primary Care Physicians (PCP) visits dietitians and durable medical equipment (DME) etc.
- Manages many aspects of the patients care: referral to specialists hospitalizations emergency department (ED) visits ancillary testing nd other enabling services.
- Available to provide telephone advice per protocol handles urgent and emergent calls.
- Anticipates the needs of this patient population seeing that necessary documentation and planning is completed for patient continuity of care.
- Works with patient and patients care team to coordinate change readiness needs assessment and develops an individualized treatment care plan.
- Assists patient in setting SMART goals for selfmanagement teaches them how to do selfmanagement tasks and reports abnormal finding to their physician team.
- Collaborates with the patient physician and other care team members in assessing the patients progress toward health care goals.
- Assesses barriers when patient has not met treatment goals is not following treatment plan of care or has not kept important appointments.
- Oversees the development procurement and adoption of patient selfmanagement educational resources used by the clinical teams.
- Collaborates with payer care managers for additional services when appropriate.
- Develops a list of medical supplies and community resources available to patients and maintains collegial relationships with the entities used most frequently.
- Works with consulting physicians hospitals ED and other frequently used healthcare sources to clarify roles and develop effective efficient and timely communication between PCPs and these entities.
- Coordinates consults referrals hospital/ED and community resource followup and tracking processes for the health system working to have clerical component done by appropriate clerical staff.
- Develops workflows and protocols within the healthcare system that ensure the ED hospital and community resource followup.
- Facilitates clinical followup with patients when indicated.
- May make home/community visits when deemed applicable to assist with social determinants of care and resolution to social barriers.
Qualifications
- Bachelors degree or higher in Social Work required upon hire
- A minimum of 1 year relevant experience preferred
- LSW Licensed Social Worker in the State of Kentucky required upon hire OR
- LCSW Licensed Clinical Social Worker in the State of Kentucky required upon hire OR
- CSW Certified Social Worker in the State of Kentucky required upon hire
Skills and Attributes
- Requires critical thinking skills and decisive judgment.
- Works under minimal supervision.
- Must be able to work in a stressful environment and take appropriate action.
Physical Demands
- Standing: Occasionally
- Walking: Occasionally
- Sitting: Frequently
- Lifting 025 lbs: Rarely
- Lifting 2575 lbs: Never
- Lifting over 75 lbs: Never
- Carrying 025 lbs: Rarely
- Carrying 2575 lbs: Never
- Carrying over 75 lbs: Never
- Pushing/Pulling 025 lbs: Rarely
- Pushing/Pulling 2575 lbs: Never
- Pushing/Pulling over 75 lbs: Never
- Climbing: Rarely
- Bending/Stooping: Rarely
- Kneeling: Rarely
- Crouching/Crawling: Rarely
- Reaching: Occasionally
- Talking: Frequently
- Hearing: Occasionally
- Repetitive Foot/Leg Movements: Never
- Repetitive Hand/Arm Movements: Frequently
- Keyboard Data Entry: Frequently
- Running: Never
- Vision: Depth Perception: Frequently
- Vision: Distinguish Color: Frequently
- Vision: Seeing Far: Frequently
- Vision: Seeing Near: Frequently
Owensboro Health Core Commitments
INTEGRITY We conduct ourselves with a high level of responsibility reliability and honesty because we take seriously the trust of our patients and coworkers.
RESPECT We value and accept the unique talents and contributions of every patient customer and team member in the Owensboro Health community.
TEAMWORK We build a spirit of connectivity and fellowship by striving together to overcome obstacles surpass goals celebrate accomplishments and plan the future.
INNOVATION We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.
SERVICE We focus on service to patients customers and team members by anticipating their needs thoughtfully meeting those needs and continually improving the quality of everything we do.
EXCELLENCE We reach beyond basic expectations to expand our knowledge and awareness produce exceptional work and provide outstanding service.
Employment Type
Full-Time
Key Skills
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