Franciscan Health Crown Point 12750 Saint Francis Drive Crown Point, Indiana 46307 WHO WE ARE With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. WHAT YOU CAN EXPECT Develop discharge plans, identifying the post-discharge needs of the patient and target appropriate resources for follow-up care, in collaboration with the patient, family and multidisciplinary care team to make the transition as smooth as possible for patients along the continuum of care. Integrate insurance, financial situation and criteria for payment in discharge plans in consideration of patient/caregiver needs. Maintain accurate, concise and timely documentation in EPIC and DOC flowsheets for discharge planning. Referral Relations Maintain good rapport with internal and external referral sources; facilitates communication with community facilities, agencies, and resources and makes appropriate referrals as needed. Document patient care information and ensures timely and accurate completion of patient care records in accordance with policies and procedures. Collaborate with a medical case manager and multidisciplinary treatment team to individualize each patient's treatment needs in order to achieve defined goals for improved patient outcomes. Educate patients and their caregivers about extended care facilities, home health agencies and other resources as appropriate, to transition patients along the continuum of care. Assess social determinates and barriers to discharge from the previously established discharge plan for readmitted patients. Perform thorough patient psychosocial assessments to explore the physical, psychological and social aspects of the patient and their conditions, obtains history, and elicits an accurate description of psychosocial needs in order to inform patient treatment plans, in collaboration with patients, their support systems and care team members. QUALIFICATIONS Indiana LSW or LCSW required Master's degree in social services field required 2 years of Acute Care Hospital, Mental Health, or related Community Healthcare experience preferred TRAVEL IS REQUIRED: Never or Rarely EQUAL OPPORTUNITY EMPLOYER It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law. Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights. Franciscan Alliance is committed to equal employment opportunity.