SOCIAL WORK TRANSITIONAL CARE COORDINATOR - STROGER

LOCATION: STROGER

SHIFT: 8:30AM to 4:30PM

SALARY COMMESSURATE WITH YEARS OF EXPERIENCE

JOB Summary seiu 73

The Social Work Transitional Care Coordinator works with an identified patient population to support the transition from facility based care to community based care. The Social Work Transitional Care Coordinator may work with patients being discharged from the hospital, skilled nursing or Cermak Health Services, those needing linkages to behavioral health services, those whose care may be impacted by changes in physician availability or those who have experienced a disruption in their insurance. Interfaces with patients, managed care representatives, physicians and community organizations. Additionally, may interact with the patient at the patient's home, physician office or health care facility.

TYPICAL DUTIES

• Outreaches to the patient and/or care giver and introduces self, performs screening if appropriate and interviews patient and/or caregiver to assess understanding of situation.
• Reaches out to facility contact to obtain information regarding discharge needs and associated plan. Where appropriate secures medical records to support post-transition care. May visit patient in facility prior to discharge.
• Develops a plan with the patient to meet the identified post discharge needs. The plan supports the patient's continuity with their medical home team, ongoing care needs and addresses social determinants that may impact the patient's ability to complete care plan activities. The plan may include home visits by the Transition Coordinator, accompanying patients to their first visits, or scheduled phone calls.
• Documents all activities in care management system according to established policy and procedure.
• Addresses social determinants through utilization of the Purple Binder software/database.
• Provides feedback to medical home teams according to departmental policy and procedure.
• Completes all training and attends educational sessions as appropriate.
• Protects PHI (Protected Health Information) and complies with Cook County Health and Hospitals System Privacy Policy.
• Reports incidents of suspected abuse, neglect and exploitation to supervisor immediately upon discovery.
• Collaborates with Integrated Care Management staff in other departments to leverage resources to support patient needs.

Minimum Requirements

• Bachelor's degree from an accredited college or university is required (must provide proof at time of interview)
• Licensed in the State of Illinois as a Licensed Clinical Professional Counselor (LCPC), Licensed Social Worker (LSW), or Licensed Clinical Social Worker (LCSW) is required
• Three (3) years of health care work experience is required
• Two (2) years of experience electronic medical record, care management systems, or scheduling software is required
• Basic proficiency using Microsoft Office (i.e. Word, Excel) is required (MS Office testing will be administered, 70% minimum proficiency rate is required)
• Valid Driver's license and mandatory vehicle insurance or other means of transportation is required

Preferred Qualifications

• Prior addiction work experience is preferred

KNOWLEDGE, SKILLS, ABILITIES & OTHER CHARACTERISTICS

• Knowledge of electronic medical record, care management systems, or scheduling software
• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Solution-oriented skills
• Ability to work at a fast-paced
• Ability to prioritize, plan and organize projects and tasks
• Ability to meet appropriate confidentiality standards for protected health information (PHI)
• Ability to adhere to department policies and standards utilizing best practices incorporating the use of electronic health record (EHR)

VETERAN PREFERENCE PLEASE READ

When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service

To take advantage of this preference a Veteran must: • Meet the minimum qualifications for the position. • Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, "Are you a Military Veteran?" • Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at ti