Social Worker Care Coordinator

UnityPoint-St Luke's Hospital

Part-Time

Weekend Package- Hours vary Saturday and Sunday

Creates optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Utilizes resources to reduce risk while serving as an ambassador between the hospital and community. Performs admission assessment, screening for appropriateness, and monitoring of plan of care to address physical and psychosocial needs, and provides problem solving assistance. Coordinates services, discharge planning, referrals to appropriate community agencies and assists with Advance Directives when appropriate. Responsible for reviewing and updating plan of care with the healthcare team when applicable. Assesses, monitors, analyzes, and documents resources utilized in the provision of patient care. Promotes communication and collaboration among all members of the healthcare team to ensure that specific outcomes are achieved and variances from accepted parameters are evaluated and addressed as needed.

Why UnityPoint Health?

• Culture – At UnityPoint Health, you matter. Come for a fulfilling career and experience  a culture  guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
• Benefits – Our competitive  Total Rewards  program offers benefits options like 401K match, paid time off and education assistance that align with your needs and priorities, no matter what life stage you’re in.
• Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
• Development – We believe equipping you with support and  development opportunities  is an essential part of delivering a remarkable employment experience.
• Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve.

Hear more from our team members about why UnityPoint Health is a great place to work at  https://dayinthelife.unitypoint.org .

Care Coordination

• Provides care coordination and discharge planning services to assure that the patient progresses through the continuum of care and has resources in place for community support
• Coordinates the integration of care coordination functions into patient care, discharge, and transition planning processes with the healthcare team, external service organizations, agencies and healthcare facilities
• Provides information regarding internal and external resources and services to patients and/or families as well as the healthcare team
• Coordinates and facilitates access to services and patient care progression using best practice interventions that will produce favorable patient outcomes within a target LOS
• Completes and documents assigned quality audits and avoidable day reporting
• Leads or co-leads Care Coordination Rounds per policy and refers patients for Complex Care Rounds
• Engages in process improvement work and quality initiatives to ensure efficient, high quality multidisciplinary care is provided
• Completes all necessary paperwork to facilitate the patient's transition through all levels of care and provides communication between community resources and the patient and/or family.

Assessment/Planning

• Assesses all assigned patients in person and integrates family information to determine potential and actual risks to recovery and the next level of care needed
• Accountable for developing and coordinating the implementation of Discharge Plan A and alternative Plan B, including documentation in the medical record
• Provides skilled intervention for the support and/or resolution of patient and family crises, problem solving, and decision making
• Improves patient and/or family understanding of and adjustment to the medical diagnosis and plan of care
• Uses established protocols to assess and promptly documents the patient’s health care needs to assure an accurate legal record of patient’s care

Relationship Building

• Collaborates with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient delivery of care in the appropriate setting
• Coordinates and facilitates patient centered interdisciplinary care and communication, ensuring progress toward goal attainment
• Supports and coaches accurate clinical documentation by physicians and other healthcare team members
• Builds a network of positive working relationships that advocate for the patient

Basic UPH Performance Criteria

• Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
• Demonstrates ability to meet business needs of department with regular, reliable attendance.
• Employee maintains current licenses and/or certifications required for the position.
• Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
• Completes all annual education and competency requirements within the calendar year.
• Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.