Centura Health connects individuals, families and neighborhoods across Colorado and western Kansas with more than 21,000 of the most talented hearts and minds in medicine.
Through Centura Health’s 17 hospitals, two senior living communities, health neighborhoods, physician clinics, Flight for Life® Colorado, home care and hospice services, we offer a diverse range of work settings in a Colorado or Kansas community you will love to call home.
Enjoy amazing people, competitive pay, some of the best benefits in the industry and plenty of opportunity for professional growth and development.
If you’re ready to discover the difference of working for a fully-integrated health system with a non-profit, faith-based mission to care, we look forward to receiving your application.
Responsible for coordinating and implementing post-discharge plans in coordination with the Case Managers through the use of Extended Care Information Network (ECIN). They are also responsible for assisting with advocacy and referrals to other community resources.
Graduate of Accredited Master's in Social Work Program
WORK EXPERIENCE REQUIREMENTS
Knowledge of community resources used for discharge planning, hospital operations, excellent communication/presentation skills, knowledge of third party payment systems, Medicare/Medicaid programs.
Maintains current knowledge base of community services through continuing education.
Ability to multi-task, set priorities and maintain organization. Computer skills.
Experience in Social Work with emphasis on discharge planning, referral to community services and/or case management or other related experience.
Current Colorado LCSW License
POSITION DUTIES (ESSENTIAL FUNCTIONS, INCLUDE % OF TIME)
DISCHARGE PLANNING & ADVOCACY - 40%
Obtains, reviews and analyzes information relative to discharge planning in accordance with hospital policy.
Assess/reassess patient's clinical and psychosocial status, premorbid status, community services utilized, and diagnosis and treatment plan per Case Management referral.
Through assessment process identifies community resources needed and facilitates referrals to agencies (local and state) or programs for assistance as needed.
Educates patient and/ or family on community resources available for assistance.
Facilitates discharge planning working with patient, families and treatment team making any needed referrals/arrangements and documenting actions.
Documents actions taken in progress notes and/or discharge planning-assessment form from initial visit through to D/C.
Demonstrates professionalism in actions and job performance in accordance with mission and the social work code of ethics.
Demonstrates and understands the needs of the following age specific categories: neonatal, pediatric, adolescent, geriatric and implements a discharge plan tailored to the age specific needs of the patient.
Demonstrate special sensitivity toward different age groups, ethnic, cultural and disabling human diversity and human development.
Conforms to standards of patient and family confidentiality according to hospital and NASW standards and HIPPA.
Assesses patient's physical, psychosocial, cultural and spiritual needs through observation, interview, review of records and interfacing with interdisciplinary team and caregivers to ensure appropriate referrals.
Reevaluates and makes adjustments to discharge plan as patients condition changes.
Ensures that appropriate arrangements for post-hospital care are made before discharge to avoid unnecessary delays in discharge.
Assesses patient/family emotional, social and financial needs and assists in setting up community resources to meet these needs.
Provides support to patients and families who are having difficulty coping effectively with changing medical conditions.
PATIENT GOALS – 30%
Confirms treatment goals and anticipated plan of care through discussions with treatment team/review of documentation.
Communicates treatment goals or best practices to treatment team including physician.
Uses ECIN to facilitate electronic referrals for discharge planning.
Uses supportive crisis intervention including illness, grief loss an decision making process.
Consults and communicates, as appropriate, with manager regarding difficult practice issues.
Adheres to state and federal regulations pertaining to discharge.
Implements discharge plan in accordance with physician direction and patient/caregiver agreement.
Assesses patient/family learning style and appropriately teaches and documents understanding.
Collaborates with interdisciplinary team to develop and implement holistic, individualized plan of care.
Works in collaboration with Case Management Coordinator, HomeCare Coordinator and Utilization Review to ensure seamless and timely delivery of services.
Maintains updated referral resource lists.
MONITORING PLAN OF CARE – 20%
Assess, coordinates and evaluates discharge readiness with CM and use of resources and discusses variances on an as needed basis with treatment team.
Participates in Family Conferences and Interdisciplinary Team Meetings on an as needed basis with Case Manager.
Reviews variance in plan of care concerning discharge planning with CM and/or CM supervisor as needed.
Completes daily discharge planning verbal rounds with CM department to prioritize daily activities.
UTILIZATION MANAGEMENT – 10%
Initiates discharge planning day one of referral to assist with LOS management.
Works with third party payors and CM to satisfy discharge planning needs and obtain approval of post discharge plans.
Implements plan and communicate possible options for d/c with regard to insurance benefits and contracted providers.
Makes appropriate outside agency referrals.
Follows through with all aspects of d/c planning across continuum of care.
* This job description is not intended to be an exhaustive list of all duties. Employee may perform other related duties as assigned.
Sedentary Work - prolonged periods of sitting and exert/lift up to 10 lbs. force occasionally)
Important notification to applicants as of Nov. 20, 2014: Effective Jan. 1, 2015, Centura Health will no longer hire tobacco users in Colorado and Kansas. The change to our policy does not apply to associates hired on or before Dec. 31, 2014. Centura Health is an Equal Opportunity Employer, M/F/D/V.
Find your ideal career at Centura Health! With 16 hospitals, physician clinics, hospice services, home care and senior living communities, Centura Health's vast network of care spans Colorado and Western Kansas so you can experience a balanced lifestyle and enjoy a fulfilling career anywhere you want to work, live and play in Colorado. From the fast pace of a Denver-area Level 1 Trauma Center to a... smaller rural or mountain hospital – we proudly offer a more diverse range of work settings and locations than any other health care employer in the state. Centura is an equal opportunity employer.