Description PURPOSE STATEMENT Collaborates with the Case Management department to assist in facilitating appropriate post-acute patient placement, utilizing hospital and community resources for continuity of patient care. ESSENTIAL FUNCTIONS • Assist with initial discharge planning assessment of patient population, establishing patient and family needs post discharge. • Assist with post-acute patient placement and discharge needs, including but not limited to skilled nursing facility referrals, arrangements for transportation, home medical equipment, home infusion therapy, hospice referrals and home health services. • Facilitate the second issuance of the Important Message for all Medicare patients and document issuance in the patient record. • Identify patients in need of assistance in acquiring medications for post-acute care and make arrangements for procurement. • Participate in multidisciplinary team rounds for review of patient’s plan of care, discharge planning and utilization management, collaborating with team members to address patient needs and desired outcomes. • Provide patient/family with information about post hospital care placement options, ensure patient choice and obtain necessary consents to refer patient to appropriate facility/services. • Maintain expertise regarding community resources. • Advocate for the patient and family throughout the entire episode of care, maintains availability to the patient/family as a resource to facilitate communication among providers and enables patient/family to make informed decisions. • Assist with documentation and capturing department metrics as directed by the UM Plan (i.e. avoidable days, delays, interventions, etc.). • Display a high level of flexibility, adaptability, and organizational skills in response to the workload and effectively prioritize work while maintaining productivity. • Cooperate with changes in staffing schedules to achieve department productivity standards. • Participate in department-based Performance Improvement activities. • Participate in department activities and provide input when appropriate. • Contribute to the development of competencies related to job functions and participate in competency evaluations. • Demonstrate attendance patterns to reflect commitment to the job requirements and patient care needs. • Demonstrate a working knowledge of HIPAA guidelines and utilize them in all aspects of communication with patients and families. • Maintain regular and predictable attendance. • Perform other essential duties as assigned. Requirements EDUCATION/EXPERIENCE/SKILL REQUIREMENTS • High school diploma or equivalent. • Bachelor’s degree in Social Work or similar field required. • Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) preferred. • Current AHA or Red Cross BLS required. • 1-3 years hospital based acute care experience preferred. • Ability to work independently as well as take direction. • Strong written and verbal skills. • Effective interpersonal skills. • Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the hospital/clinic. PHYSICAL/MENTAL REQUIREMENTS • Must be able to sit and stand, intermittent 8 to 10 hours a day. • Must be able to use standard office equipment, including the telephone and computer keyboard. • Continuously works under pressure of near 100% accuracy while meeting inflexible deadlines. • Continuously utilizes manual/bi-manual dexterity, near vision, speech, and hearing.