NewYorkRecruiter Since 2001
the smart solution for New York jobs

Social Worker - Transition of Care

Company: Centers Plan for Healthy Living
Location: Staten Island
Posted on: August 7, 2022

Job Description:

Social Worker - Transition of CareStaten Island, NY, USA Req #1020 Friday, July 15, 2022Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living.Summary The Care Transition Specialist is a core member of the CPHL Interdisciplinary Care Team (ICT) and works collaboratively with the I-SNP nurse practitioners to ensure the coordination and continuity of care as members move between different settings and levels of care to improve quality of care and reduce unnecessary hospitalization. Essential Functions

  • Develop and facilitate collaborative partnerships with all members of the ICT
  • Participate in case discussion conferences related to hospital admissions, high-risk complex cases, and care planning
  • Document relevant care transition planning information in the medical record according to Department standards
  • Communicate and collaborate with hospital staff on development of discharge needs/ plan
  • Educate hospital staff of I-SNP Model of Care and clinical skill level of nursing facility to promote early discharge to nursing facility.
  • Facilitate, address and resolve system problems impeding non-emergent diagnostic or treatment progress with the assigned population; proactively identifies and resolves delays and obstacles to coordinated care
  • Coordinate communication with team and responsible parties (family) about transition process in accordance with Department policies and procedures
  • Develop care plans based on nurse practitioners plan of care for all new members and annually thereafter in accordance with MOC and Department policies and procedures
  • Monitors adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
  • Facilitate member access to health care services, identify network providers and work with the UM Department to obtain authorizations as needed
  • Collaborates and assists care team in identifying level of care changes
  • Receive, process and generate facility reports related to skilled level of care service days
  • Monitors and report data on core MOC requirements
  • Work closely with Management Team on development and implementation of methods, policies and procedures to improve the Departments efficiency and overall effectiveness
  • Particaptes in the development of clinical pathways, best practice standards, competency processes Competencies
  • Excellent verbal and written communication and interpersonal skills
  • Ability to handle multiple tasks/projects concurrently
  • Strong skills in coordination of discharge planning, cre plan development and implementation and follow up
  • Proficiency Microsoft Office applications (Word, Excel) and other data collection programs
  • Ability to demonstrate effective critical thinking and problem solving skills. Supervisory Responsibility This position has no supervisory responsibilities. Work Environment This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, and photocopiers. Physical Demands This is largely a sedentary role. Position Type and Expected Hours of Work This is a full-time position. Days and hours of work are Monday through Friday, 9am to 5pm. Some travel to hospitals and nursing facilities may be required Required Education and Experience
  • Bachelor's / Masters degree in social work .
  • 3-5 years of experience in a health care setting, preferably long term care.
  • Mimium of 3 years managed care experience required.
  • Knowledge of Medicare/Medicaid bemefits and regulations required. Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our employees and our business. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment.Other details
    • Pay Type Salary Apply Now
      • Staten Island, NY, USA

Keywords: Centers Plan for Healthy Living, New York , Social Worker - Transition of Care, Healthcare , Staten Island, New York

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Log In or Create An Account

Get the latest New York jobs by following @recnetNY on Twitter!

New York RSS job feeds