Care Coordinator Social Work LMSW

About the position

The Care Coordination Social Worker (LMSW) at Nuvance Health is a vital role responsible for providing comprehensive counseling, crisis intervention, and complex discharge planning services to both inpatients and patients in designated outpatient areas. This position requires a proactive approach in collaborating with the Clinical Care Coordinator to design effective discharge plans tailored to the unique needs of each patient. The Care Coordinator will manage an assigned group of patients, particularly those with complex discharge requirements, ensuring that all necessary services, equipment, and transportation are confirmed for the day of discharge. In instances of delays or late discharges, the Care Coordinator is responsible for notifying the appropriate members of the healthcare team to facilitate timely resolutions. In addition to discharge planning, the Care Coordination Social Worker serves as a critical resource for the Clinical Care Coordinator in the Emergency Department (ED), identifying and implementing discharge options while providing essential counseling to patients and families in crisis. This includes offering substance abuse counseling, financial need referrals, and grief counseling, as well as providing staff support during times of traumatic loss. The role also encompasses specialized services in Maternal/Child Health, where the social worker provides grief counseling for fetal demise and sudden death, and participates in multidisciplinary rounds in the Neonatal Intensive Care Unit (NICU). The Care Coordinator is tasked with assessing patients for potential abuse or neglect, reporting findings to the appropriate agencies, and initiating conservatorship applications when necessary. Leading patient and family conferences, providing resources for Advanced Directives, and ensuring compliance with all responsibilities related to the position are also key components of this role. The Care Coordination Social Worker must maintain effective communication with all stakeholders, including supervisors, peers, physicians, and interdisciplinary team members, to keep them informed about patient progress and any barriers to discharge.

Responsibilities

• Completes assessments and collaborates with the Clinical Care Coordinator to design appropriate discharge plans.
• Manages an assigned group of patients, including those with complex discharge plans, ensuring all services and equipment are confirmed for discharge.
• Serves as a resource to the POE Clinical Care Coordinator to identify and implement discharge options in the ED.
• Provides counseling to patients and families in crisis, including substance abuse counseling and grief counseling.
• Assesses assigned patients for abuse/neglect and reports findings to appropriate agencies and internal departments.
• Initiates and coordinates applications for conservatorships, working with legal counsel and courts as needed.
• Leads patient and family conferences and provides resources for Advanced Directives.
• Completes readmission assessments for patients readmitted within 30 days of discharge.
• Informs the Clinical Care Coordinator of any changes to discharge plans or barriers to discharge.
• Fulfills all compliance responsibilities related to the position.

Requirements

• Master's Degree in Social Work (LMSW) required.
• Minimum of three years of counseling and discharge planning experience in an acute care hospital or equivalent.
• Demonstrated discharge planning and implementation skills.
• Ability to analyze financial and social situations, identifying problems and alternative courses of action.
• Flexibility, resourcefulness, and creativity in problem-solving.
• High degree of prioritization skills and ability to act independently.
• Effective communication skills with physicians, patients, families, and interdisciplinary team members.

Nice-to-haves

• Case Management Certification preferred.