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• Documents clinical record, comprehensive assessment of patient needs including barriers to timely discharge, clinical interventions, support and appropriate community resources according to policy and utilizing recognized format, such as, assessment, intervention, and plan. Documents clinical record appropriate interventions including assessment, plans, and referrals in the discharge planning process.
• Documents in clinical record all referrals and clinical interventions related to abuse, neglect, domestic violence, alcohol and substance abuse, crisis intervention. Performs educational sessions for health care team related to abuse/neglect issues and reporting of same. Documents staff interventions in clinical record.
• Updates the health care team on the progress of managing the social and financial barriers that delay appropriate transitions during multidisciplinary rounds, length of stay meetings, and medical record documentation.
• Advocates for appropriate services for complex patients with payor and providers of post-acute care service, community service and other services in order to optimize patient outcome.
• Leads complex care rounds and organizes and participates in family meetings with providers and the multidisciplinary team to coordinate transition of care.
• Manages contract patients discharged from the hospital to ensure the post acute facility is working in the best interest of the patient and the hospital system.
• Prepares all documents for guardianship proceedings including investigator reports, medical and psychiatric notes and documents required from the legal department.
• Uses culturally competent skills to assess individual patient needs and refers to appropriate professional staff when necessary. Identifies barriers and plans for intervention to overcome or lessen barriers to achieve outcome as evidenced by treatment plan.
• Performs other duties as assigned.

• Master's degree in Social Work (MSW) or Registered Nurse (RN).
• Three years experience in a clinical setting performing clinical social work or case management.
• AHA BLS - Healthcare Provider,Social Worker - Licensed
• Excellent communication,conflict management,organizational and planning skills
• Clinical training in a medical/clinical environment; knowledge of spreadsheet and word precessing software, case management and patient information systems.

Offers are contingent upon successful completion of our onboarding process and pre-employment physical.  Capital Health will require all applicants (including contractors, travelers and consultants) to have an annual flu vaccine and to have a completed COVID-19 vaccine prior to start date, with the exception of individuals with medical and religious exemptions.

"Company will never ask candidates for social security numbers or date of birth during application phase. If you are asked for this information online, you may be a target for identity theft."

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