Responsibilities

The Care Coordinator Social Worker Sr. serves as an expert resource for complex patients/ situations and serves as a guide/consultant to the other care team members surrounding patient psychosocial and resource needs. Is an expert with supporting community-based service offerings (indigent care support groups, specialty care) and offers guidance to patients/families as well as other care team members. Is responsible for selected functions related to Advance Directives.
The Care Coordinator SW Sr. is responsible for providing psychosocial assessment for patients with the appropriate planning for follow up care. The Care Coordinator SW Sr. collaborates with the interdisciplinary team to provide care and support to the patient and family in a wholistic manner and serve as an expert on issues related to psychosocial, end of life care, planning, resource needs, counseling services utilizing evidence-based standards and appropriate documentation n the patient record. The Social Worker will provide resource and information necessary to aid patient/families in decision making up to and including support for end of life or funeral care. The Care Coordinator SW Sr. role include, discharge planning and assessment of patients and family’s needs for post discharge services, including post-acute care and placement, transition of care, pharmaceutical applications, providing information and counseling services to help the patient cope/adjustment to illness, hospitalization, anticipatory grief, death and bereavement, and other situations that may arise.
The Care Coordinator SW Sr. will collaborate/participate in ensuring that education on chronic care conditions selfmanagement such as CHF, COPD and other key focus conditions are completed. The Social Worker will coordinate and lead family conferences to plan timely patient disposition, will guide and support the other Social Workers with family care conferences and physician level meetings. The Social Worker will participate in the training of new social work hires and may assist other LMSWs in case reviews and discussion of difficult situations, to include, but not limited to assessing suicide ideation, bereavement risk and other similar scenarios. May have other duties assigned as appropriate.

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