Transition Care Social Worker

Job Title: Transition Care Social Worker

Job Description:
The goal of the Transition Care team is to ensure a seamless transition from hospital to home or next setting. As part of the Transition Care team, the transition social worker will perform social service functions, working closely with patients and families. Responsibilities include taking psycho social assessments, participating in interdisciplinary care planning meetings, assisting with discharge planning, and following patients in the community for 30 days post discharge through phone calls and may include visits to patients at home in order to identify and provide the appropriate referrals and responses for the psycho social barriers which may contribute to unnecessary ER visits and hospitalizations in that period. This may include referrals for long term care plans to assist pts ongoing and beyond the initial 30 day period.
Duties and Responsibilities:

• Participates in transition care planning while patient is hospitalized
• Identifies psycho social needs and makes appropriate referrals.
• Assesses insurance status and identifies gaps (patient needs MLTCP, eligibility for Medicaid- dually eligible, checks recertification date(s) for insurance plans and makes sure plans are active.
• Assesses if patient has family and community resources to meet his/her needs and discusses options with patient, and assess caregiver(s) availability and training needs.
• Review patient’s insurance plan(s) to ensure patient/caregiver understand coverage and re enrollment deadlines. Recommend alternatives if needed.
• Assesses need for long term plans and initiates appropriate referrals
• Identifies entitlements and benefits for which patient is eligible and initiates applications
• Assesses housing security (ability to pay rent threatened eviction, etc.) and assists to resolve issues.
• Follows patient for 30 days after discharge through phone calls and may include home visits too
• Assesses psycho social barriers to health care and makes appropriate referrals.
• Continues to follow up on all referrals made to ensure services are implemented
• Initiates case conferences with Transition Care team as needed and reports problems/concerns to Transition Manager
• Provides support and information on the social and emotional effect of patient’s disease on patient and caregiver(s).
• Attends in services, trainings and meetings as required.
• Documents all encounters and activities on behalf of patients in the chosen electronic record. Makes sure relevant information on patient’s status is shared with all service providers.

Requirements:

• Licensure preferred
• Experience in healthcare settings, behavioral health, and chronic disease. Home Health care experience a plus.
• Experience in care coordination or case management
• Bilingual English/Spanish/Haitian Creole preferred
• Extensive knowledge of Medicare and Medicaid, entitlements, benefits, and community resources
• Excellent communication and customer service skills. Must be compassionate
• Experience in email systems, knowledge of and experience with Microsoft office products. Experience with electronic medical records preferred.
• Travel may be required on public transportation anywhere in New York City.