Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care, and two urgent care offices. Non-acute care is offered through various affiliates, including the Thompson House for rehabilitation and skilled nursing services, and the Home Care organizations.
The Care Coordination Social Worker (LMSW) is responsible for providing counseling, crisis intervention and complex discharge planning services to assigned inpatients and patients in designated outpatient areas. Participates in discharge plan design with the Clinical Care Coordinator on the units or in the ED. Seeks conservatorships when needed and is knowledgeable about all available community resources.
1. Completes assessments as needed and collaborates with the Clinical Care Coordinator to identify needs and design an appropriate discharge plan. Manages an assigned group of patients, including those with complex discharge plans. Implements the plans and with the Care Coordination Assistants ensures that all services and equipment and/or transportation are confirmed for day of discharge. Notifies appropriate members of the healthcare team of any delay or late day discharges.
2. Serves as an assigned or on call resource to the POE Clinical Care Coordinator to identify and implement discharge options in the ED. Provides counseling to patients/families in crisis, offer substance abuse counseling and referrals, financial need referrals and grief counseling. Provide staff support at times of traumatic loss. Keeps Clinical Care Coordinator informed appropriately. Provides education to ED.
3. Maternal/Child Health:
Provides grief counseling for fetal demise, sudden death as well as providing referrals for identified needs. Participates in MDR’s in NICU.
4. Assesses assigned patients for abuse/neglect, domestic violence, and reports to appropriate agencies, Clinical Care Coordinators and other internal departments per protocol. Initiates and coordinates applications for conservatorships, works with appropriate legal counsel and courts as needed.
5. Lead patient and family conferences as needed. Provide Advanced Directive resources as needed as well as the Patient Right to Choose information for selection of post-acute hospital care.
6. If patient has been readmitted within 30 days of discharge, complete the readmission and CARL tool.
7. Ensure that Clinical Care Coordinator is informed of any changes to discharge plan or barriers to a safe and timely discharge.
8. Fulfills all compliance responsibilities related to the position.
9. Performs other duties as assigned.
Requires a minimum formal education of Master's Degree in Social Work and a minimum of three years counseling and discharge planning experience in an acute care hospital or equivalent, and demonstrated discharge planning and implementation skills. Analyze financial and social situations, identifying problems and alternative courses of action. Ability to be flexible, resourceful and creative in problem solving. Requires a high degree of prioritization skills. Ability to act independently and offer suggestions and new ideas for improving performance and operations. Keeps supervisor, peers, physicians, interdisciplinary team members, patients and families informed about progress, problems and developments. Proofread and check documents for errors as well as the ability to use a keyboard to enter, retrieve, and transform data. Effectively communicate with physicians, patients, families and other members of the interdisciplinary team. Minimum Experience: three years Desired: Case Management Certification preferred.
Norwalk-34 Maple St
1030 a.m. - 700 p.m., variable
- Some manual skills / motor coord & finger dexterity
- Little or no potential for occupational risk
- Medium to Heavy effort. May exert up to 35 lbs. force
- Generally pleasant working conditions.
Nuvance Health and its affiliates are Section 501(c)(3) tax-exempt organizations and therefore eligible employees may qualify for forgiveness of certain federal student loans under the Public Service Loan Forgiveness Program.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Qualified Applicants are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other classification protected under applicable Federal, State or Local law.
We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-739-7330 (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.