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Collaborates with the physician, other health care professionals, patient family in the design and documentation of an explicit home health plan of care. Implements and evaluates the progress of the plan of care. Collects key data elements which describe the achievement of quality/performance improvement and utilization/financial goals.

MINIMUM QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Master's Degree in Social Work from an accredited school of social work. 2. Current licensure to practice Social Work in the appropriate state where services will be provided. 3. Valid driver's license. 4. CPR certification within 30 days of hire date.

PREFERRED QUALIFICATIONS: EXPERIENCE: 1. Two (2) years of Home Health experience. 2. Experience with counseling individuals or groups. 3. Experience with psychosocial, emotional, and spiritual assessment.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an exhaustive list of all responsibilities and duties. Other duties may be assigned.

1. Completes comprehensive assessment to develop a safe, realistic discharge plan of care appropriate for the patient.
2. Assesses changes in the physician's plan of care and the impact on the discharge plan. Initiates discharge planning in collaboration with care team.
3. Reviews discharge plan on an ongoing basis and communicates changes in the plan to the appropriate parties.
4. Documents discharge plan in patient's chart on a frequency that communicates the plan to interdisciplinary team.
5. Ensures that discharge needs are met prior to discharge.
6. Assesses for signs and symptoms of abuse and/or neglect and makes referrals to appropriate agencies.
7. Identifies decision maker of medical (financial, if indicated) or if there is an existing Medical Power of Attorney designee and presence of Living Will or other advanced directives. Assists patient in completion of Living Will and Medical Power of Attorney forms as requested.
8. Works with legal counsel in pursuing and expediting guardianship, and/or conservatorship actions when necessary.
9. Assists in planning, implementing and evaluating QI strategies.
10. Provide care, based on physical, psychosocial, communication, safety, education level, and related criteria for the infant, pediatric, adolescent, adult, geriatric patient per the established age-specific standard.
11. Communicates to leadership and/or appropriate physician/medical staff director/peer review. Deviations from expected norm, quality or appropriateness of care according to established standards of care. Risk management issues.
12. Explains to physicians, patient, family and other health care professionals Medicare, Medicaid and other 3rd party payers coverage issues and regulations.
13. Identifies potential problems with post-discharge care and/or initiates early referrals to promote timely transfer and proper utilization of resources.
14. Takes appropriate actions to minimize financial loss to the organization and/or improve the quality of patient care delivery (i.e., discusses cases with patients and families, consult with physician).
15. Formulate and execute a safe discharge plan in an expeditious manner.
16. Performs needs assessments reflecting patient/family psychosocial, emotional, spiritual, financial, and age-specific criteria upon admission and each visit thereafter, including development of an... For full info follow application link.