Sparrow Health System
Positions Location: Charlotte, MI
General Purpose of Job:
Coordinates team-based care to provide mental and social health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a "shared goal model” within and across settings to achieve coordinated high-quality care that is patient- and family-centered.
- Supports and serves as a role model for our mission, vision, values and customer service initiatives. Adheres to the organization’s policies and procedures and compliance guidelines. Core values consistent with a patient/family-centered approach to care.
- Provides mental and emotional care coordination through the continuum to improve patient outcomes, reduce readmissions and cost and enhance the patient/family experience.
- Implements plan of care providing intervention and emotional support to referred patients and their families/support system. Other interventions may include assistance with identification of community resources, long-range planning and decision-making, and interaction with legal and regulatory agencies as required.
- Develops and maintains working relationships with community agencies and services to promote interagency cooperation and facilitate related referrals.
- Functions as a member of the Utilization Review/Case Management team attending required meetings and maintaining communication with other disciplines to facility quality patient care, resolve problems and exchange information.
- Coordinates the transitional care management (TCM) including collaboration with other disciplines, to identify the patient’s discharge planning needs, assist the patient/family in developing a plan, coordinating arrangements to meet the discharge planning needs, arranging for transfer to facilities providing alternate levels of care when indicated, preparing written correspondence for external contacts as needed and assisting the patient for 30 days post discharge to prevent readmission.
- Completes required documentation in a timely manner.
- Facilitate patient access to appropriate medical and specialty providers well as other care coordination team support specialists (Diabetes Educator, Dietitian, Community Paramedic).
- Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
- Attend and actively participate in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other Care Coordinators and Coach).
Performs other duties as assigned.
|General Requirements||Valid State of Michigan Social Worker Licensure preferred.|
|Work Experience||Minimum of one year of related social work experience|
|Specialized Knowledge and Skills||Knowledge of social work theory and counseling techniques * Knowledge of available community resources * Knowledge of accrediting and regulatory standards and hospital policies related to the provision of patient care including HIPAA confidentiality and TJC mandates * Written and computer skills necessary to prepare required documentation * Interpersonal skills necessary to develop and maintain productive working relationships with patients and their families, physicians, health care professionals, and various community agencies. The incumbent is required to have effective verbal and written communication skills * Analytical ability to assess patient's progress and to determine appropriate intervention based on social work theory and incorporation of patient and physician goals * Mental ability to adapt and respond to multiple priorities and demands, deal with the concerns/emotional needs of patients/families, resolve problem situations in a positive manner, and respond to emergency situations|
Sparrow Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.JOB REQUIREMENTS: <img height=1 width=1 border=0 src=https://sparrowhealthsystem.contacthr.com/80246261.jpg /> To apply for this position, please copy and paste the following link into your browser address bar: https://sparrowhealthsystem.contacthr.com/80246261
Preferred Years Of Experience:1 Year(s)
Education Required:Masters Degree - MA
Employment/Position Type:Full Time
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