Join a dedicated Care Transitions team providing compassionate patient and family advocacy alongside 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 through home visits and assessments that consider social, cultural, emotional, and spiritual factors. Collaborate with care management staff and interdisciplinary teams to develop tailored psychosocial intervention plans that address patient and family needs. Incorporate cultural values and beliefs into care strategies, aiming to reduce hospital readmissions and emergency visits. Work closely with care providers to overcome psychosocial and financial barriers impacting patient compliance and progress. Respond appropriately to cases involving suspected violence, abuse, or neglect, adhering to professional social work ethics. Facilitate advance care planning including end-of-life discussions, healthcare proxies, living wills, and power of attorney arrangements. Stay informed on evolving care management trends, regulatory requirements, and payer policies. Utilize performance metrics to enhance patient safety, satisfaction, and equitable care. Maintain accurate and timely documentation in compliance with privacy regulations. Foster positive relationships with patients, families, colleagues, physicians, and referral sources.

Minimum Knowledge and Skills

• Proficiency with MS Office and keyboarding skills
• Strong communication and multitasking abilities
• Expertise in social work assessment and counseling
• Familiarity with state and federal medical and financial support programs

Behavioral Skills

• Integrity: Demonstrates honesty and ethical behavior, inspiring others to uphold organizational values.
• Compassion: Exhibits empathy and excellent customer service, managing conflicts thoughtfully.
• Accountability: Takes ownership of projects and adapts flexibly to changing priorities.
• Respect: Collaborates effectively with diverse populations, maintaining a positive service orientation.
• Excellence: Communicates persuasively, leads teams strategically and tactically, and drives process improvements.

Education and Experience

• Completion of an accredited Bachelor of Social Work (BSW) program is required.
• Preferred experience includes several years in medical facilities, hospice, or home care settings.

Licenses and Certifications

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

This opportunity is based in a regional healthcare setting within the Central Plains area of the United States, offering a competitive salary and comprehensive benefits. Join a team committed to delivering exceptional care and support to patients and families throughout their healthcare journey.