Job Description

It would be helpful for them to have hospital experience, experience with discharge planning, EPIC experience,familiar with the Rochester area preferred . May take local. Will take SW with BA or Masters level.Key Responsibilities: Interviews patients, residents and/or families, engages in chart review, and completes and documents a comprehensive psycho-social assessment and high risk evaluation to identify patient, resident and/or family psycho-social needs at time of preadmission or upon admission. In collaboration with the interdisciplinary team develops and documents a comprehensive plan to address the needs identified through the comprehensive psychosocial assessment in compliance with professional, regulatory and facility standards. In collaboration with members of the interdisciplinary team participates in daily rounds developing care plans, delivering service and for discharge planning, including making appropriate referrals for medical, behavioral health, and social needs of patients, residents and families. Facilitates efficient patient/resident transitioning through the care continuum fostering self determination and individual decision making. Understands placement intricacies and can interpret requirements from federal, state and local agencies to optimize the placement of patients/residents in the most appropriate setting. Aligns needs of patients/residents with appropriate placement options. Serves as a resource to the health care team on issues including the emotional, social, and psycho-social components of patient/resident illness, guardianship, abuse/neglect and advance directives. Works in collaboration with department leadership, Financial Case Manager, health care insurance providers (i.e., HMO s, private insurance, Medicare, Medicaid), etc., to advocate for the patient/resident/family and to obtain approval for coverage as documented in the record. Involves patient/resident/family in the treatment planning process as demonstrated by medical record documentation and signatures on the appropriate forms. Provides age appropriate interventions including counseling, crisis intervention, education, and referral to patients, residents and families to impact problems related to environmental needs, family and interpersonal conflict, or physical and/or mental illness. Executes the plan of discharge and notifies involved parties (i.e., patient, resident, family, physician, facility, etc.) concerning the discharge within 24 hours of discharge authorization.

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