Position Summary

• The Care Coordinator coordinates services within the clinic and hospital setting, ensuring continuity of care for patients and helping the patient utilize all needed resources in the community. Will work closely with providers and clinical staff to assist in providing the best evidence-based care for patients for better patient outcomes, including chronic disease coordination, social determinants of health, and care transitions.

• Education and Experience Requirements
  • EDUCATION:
    • Required:
      • Bachelor’s degree in social work, sociology, psychology, nursing, or related field.
    • Preferred:
      • Master’s degree in social work (MSW)
  • LICENSES AND CERTIFICATIONS:
    • Required:
      • Valid Driver’s License
    • Preferred:
      • Licensed Social Worker highly preferred
  • TRAINING AND EXPERIENCE:
    • Required:
    • Preferred:

• Essential Job Functions
  • Evaluate patient needs by interviewing patients, families, and/or significant others to obtain information about home environment, family relationships, and factors that may impact the patient's illness, treatment, and rate of recovery.
  • Provide case management to patients and families by consulting with nursing staff, providers, and other disciplines in a cooperative effort to provide optimal services.
  • Assess, develop, implement, and monitor a comprehensive plan of care through an interdisciplinary team process in conjunction with the patient and family. Collaborate with the multi-disciplinary team to identify problems or needs that require special planning, intervention, teaching or follow-up.
  • Facilitate health equity strategies to attain the highest level of health for all people that enable them to lead healthy lives by focusing on health disparities, social determinants of health, and the social needs of all individuals.
  • Consult and collaborate with providers, nurses, and support staff within the Emergency Department, Rapid Care, Primary Care Clinics, Specialty Clinic, Surgery Clinic, and other outpatient patient care departments to meet the needs of the patients.
  • Act as a community liaison, facilitating referrals to appropriate public and private health and welfare agencies to communicate patient needs.
  • Complete necessary paperwork and report filing for the involuntary commitment process or delegate/educate others as appropriate.
  • Serve as a resource for patient healthcare decision-making, including advance directives, living wills, healthcare POA, etc.
  • Facilitate referrals and coordination to other services (e.g., substance abuse treatment, telepsychiatry, or community resources) as needed or as directed by the primary care provider. Develop/maintain a professional relationship and act as a liaison with local mental health agencies to enhance coordination of patients being referred for services at their facility.
  • Maintains flexibility as census/acuity and staffing changes. Accepts assignments to other areas as requested by supervisor. Supports fellow team members by periodically assessing team members' workload and providing assistance as needed.
  • Performs all other duties as assigned.