The Senior Social Services Coordinator works collaboratively with the Genesis Care Transitions team to ensure that Social Services delivery is consistent and in compliance with federal, state, and local guidelines, regulations, Genesis Policies - Procedures, and standards of care. This position is responsible for working with other members of the interdisciplinary team to foster a climate, and routines that enable patients to manage their own care, maintaining individuality, independence, and dignity. This climate will encourage patients to maintain the highest practical level of physical, mental, and psychosocial well-being to achieve their goals and remain out of the hospital. The position involves supervision of all the Genesis Care Transitions Social Services Coordinators as well as providing direct care to patients.
Direct Care to patients:
Identifies and follows patients for a 30 -90 day period, depending on the payer.
1. Works closely with patients and caregivers to identify support services necessary to transition safely to the community, initiating referrals when it's appropriate. Provides key information regarding clinical, financial and social considerations to support decision-making. Services must be provided in accordance with the National Association of Social Workers code of ethics and in compliance with federal, state and local guidelines and regulations, as well as with Genesis policies and procedures.
2. Collaborates with center-based social services staff to assist in identifying and developing a network of strong relationships with the highest quality community based providers. Through continuous follow-up on referrals.
3. Develops and maintains an extensive and comprehensive network of preferred providers.
4. Assists patients in choosing appropriate resources, scheduling appointments. Also assists with financial and logistical issues to improve access.
5. Communicates frequently with Transitional Care Nurses regarding patient cases to provide real-time information regarding placement with community based providers, appointments scheduled, identified issues; including rehospitalizations, and to facilitate communications with home health agencies and other community based providers.
6. Position is telephonic. The introductory call is made by the Senior Social Service Coordinator upon discharge to the patient. A social service assessment is completed. Feedback is given to the Transitional Care Nurse on the team. The Senior Social Service Coordinator may conduct follow up phone calls to patients/caregivers during the 30-90 day episode of care.
7. Documents information regarding patient /caregiver satisfaction with center stay.
8. Makes follow up calls as assigned working closely with the TCN on a weekly basis and as needed to identify unmet needs and clinical issues to prevent unnecessary re-hospitalizations. Follows up with TCN regarding a change in the patient's condition or clinical needs. The Senior Social Service Coordinator may assume the team lead if a patient is discharged other than home such as to assisted living or another skilled nursing facility, make contact with Hospice agencies if the patient is Hospice and if patient's needs are more social concerns than medical and take over making the weekly or bi-monthly calls.
9. Collect key data elements for research/outcomes reporting and to identify risk factor by completing the Post Discharge Risk for Readmission Evaluation. Maintains and disseminates daily reporting system for all patients admitted to and discharged from center (in center, at home, closed, ineligible, re-hospitalized, capturing and documenting key patient level information.
10. Performs all related direct care duties as requested
1. Plans, organizes, implements and evaluates and directs a comprehensive Social Services program, while always remaining responsive to the team of Transitional Care Nurses and Genesis Care Transitions management team.
2. Recruits, interviews, select, supervise and evaluate all social services staff.
3. Coordinates and implements Social Service orientation and training for new members of the Genesis Care Transitions team. Monitor whether continuing education requirement is being followed by social services staff.
4. Works with the Director to determine staffing, and budgetary needs for the social services
department within Genesis Care Transitions.
5. Performs all related supervisory related duties as requested.
1. Complies with applicable legal requirements, standards, policies and procedures including but not limited to those within the Compliance Process, Standard/Code of Conduct, Federal False Claims Act and HIPAA.
2. Participates in required orientation and training programs.
3. Promptly reports concerns and suspected incidences of non-compliance to supervisor, Compliance Liaison or to the Compliance Officer via the Integrity Hotline.
4. Cooperates with monitoring and audit functions and investigations.
5. Participates, as requested, in quality assurance and process improvement activities.
Position Type: Full Time
Req ID: 325731
Center Name: Pleasant View Center