Join a dedicated Care Transitions team providing compassionate patient and family advocacy along with psychosocial support for individuals referred to the care transition program. This role focuses on promoting wellness, enhancing care outcomes, facilitating advance care planning, and ensuring access to post-acute physician services, hospital or outpatient care, and community resources.

Essential Functions

Systematically collect relevant psychosocial data to identify patient and family needs and implement appropriate interventions. Conduct home visits to perform comprehensive psychosocial assessments that consider social, cultural, emotional, and spiritual factors. Collaborate with care management staff and interdisciplinary teams to develop focused intervention plans tailored to patient needs, incorporating cultural values and beliefs related to illness, disability, and end-of-life care.

Work closely with healthcare teams to reduce hospital admissions and emergency visits by addressing psychosocial and financial barriers. Respond professionally to cases involving suspected violence, abuse, or neglect. Facilitate advance care planning including healthcare proxies, living wills, advance directives, and power of attorney. Stay informed on evolving care management trends, regulatory requirements, and payer policies.

Maintain accurate and timely documentation in compliance with privacy regulations. Foster positive relationships with patients, families, colleagues, physicians, and referral sources through respectful and empathetic communication.

Minimum Knowledge and Skills

• Proficiency with MS Office and keyboarding skills
• Strong communication and multitasking abilities
• Social work assessment and counseling expertise
• Knowledge of state and federal medical and financial support programs

Behavioral Skills

• Integrity: Demonstrates honesty and ethical behavior
• Compassion: Exhibits empathy and excellent customer service
• Accountability: Takes ownership and adapts to changing priorities
• Respect: Collaborates effectively with diverse populations
• Excellence: Strong leadership, strategic thinking, and process improvement skills

Education and Experience

Completion of an accredited Bachelor of Social Work (BSW) program is required. Experience in medical facilities, hospice, or home care is preferred.

Licensure and Certification

Current licensure as a BSW in the relevant state and Healthcare Provider Basic Life Support (BLS) certification are required.

Enjoy competitive pay, a generous benefits package, and the opportunity to make a meaningful impact in a regional healthcare setting serving the Central Plains area.