COMPLEX CARE COORDINATOR, SOCIAL WORKER

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$10,000.00 Sign on bonus ! 

 

MAJOR FUNCTION:  

The Complex Case Coordinator is responsible to oversee complex cases at Inspira Health Network in collaboration with the hospital’s care coordination team, behavioral health team and other healthcare providers.

Complex cases are defined as patients coping with multiple different issues, ranging from medical, mental health, or end-stage disease with complex social and financial situations. The Complex Case Coordinator is responsible to collaborate within the interdisciplinary team to perform care coordination for high-risk patients to ensure continuity of care and quality healthcare delivery across the care continuum.

The Complex Case Coordinator will work to improve quality, patient experience and throughput while achieving cost efficiency and reduce length of stay at Inspira Health. This position will partner with the interdisciplinary team to ensure complex case management strategies are executed on a concurrent basis at the local level.

 

Essential Responsibilities / Functions of Position:

  • Provide psychosocial assessment on patient and assess over time the health care, educational, and psychological needs of the patient and family.
  • Collaborate with the interdisciplinary team, such as the physician, nurses, patients, social work and other members of the health care team, including continuum of care settings and community. Continually monitors patient/family response to plan of care and revises the care plan as indicated.
  • Spanning the ED/ Observation, in-patient, post-acute and transitional care settings
  • Coordinate management of patient through various community resource options. Integrates information obtained from the patient's chart and from communications with various sources when discussing the level and intensity of care needed.
  • Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinate care across settings and helps patient/families understand health care options. Collaborates and communicates patient findings to primary care provider, Care Coordination Team, and healthcare providers, identified care-partner(s) as appropriate across various health care settings via timely, accurate, and clear communication modalities.
  • Utilize evidenced based risk stratification tools to proactively assess chronically ill populations, identify patients at risk for disease -related consequences and deliver patient centered evidence-based interventions to prevent future progression or exacerbation of illness.
  • Responsibility for the management of medical, psychiatric and/or socially complex patient populations for assigned hospitals to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services.
  • Identifies Social/Behavioral Health needs which impact patient outcomes and follow through on appropriate referral(s).
  • Assess and refer patients to available community support services as deemed necessary.
  • Collaborates with interdisciplinary team to develop innovative strategies addressing the needs of the population.
  • Provides patient/care partner(s) education regarding prevention /recognition /treatment of disease exacerbation and promote self-management of the medically complex patient.
  • Provides a daily report on all complex cases to Manager of Social Work in Care Coordination.
  • Work with insurances to obtain authorization for services (subacute rehab, inpatient psychiatric facility, in-home care services) arrangements to facilitate the patient's timely transition through the care continuum. Notify attending physician, treatment team, and others as needed.
  • Provide patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
  • Responsible for tracking Complex Case List
  • Must take weekend call once every 4th weekend

 

 

Education: Graduate from a CSWE accredited School of Social Work with an MSW (Master’s in Social Work) degree. State licensure required by the NJ State board of social work examiners. Licensed social worker (LSW) required, licensed clinical social worker (LCSW) preferred                              

 

Experience:   

Minimum of three years of post-master’s in social work in the acute care setting 

 

 

Certification/Licensure: 

Current licensure as a Social Worker in New Jersey,  as an LSW required or LCSW preferred. Certification in

Aging & Health, Addictions, Behavioral Health, Palliative Care preferred        

 


At Inspira Health, you’ll join with the area’s most dedicated and distinguished team to bring quality and compassionate care to our communities. We focus on clinical excellence, providing evidence-based care to help each patient achieve the best possible outcome. The scope and depth of our network can open many doors for your learning and career growth.


Our charitable nonprofit health care organization serves communities across southern New Jersey. The network, which traces its roots to 1899, comprises three hospitals, a comprehensive cancer center, sleep medicine, cardiac testing, digestive health and wound care, urgent care, imaging and rehabilitation, and primary and specialty physician practices in Gloucester, Cumberland, Salem and Camden counties.