In Collaboration with the care team and other health care professionals is responsible for implementing an interdisciplinary process for evaluating a patient's progress from admission through return to the community for a specific caseload of patients. This includes anticipating the clinical course of patients, assessing response to treatment, identifying and initiating actions to reduce delays/rework and enhance cost-effective use of resources, identifying and initiating discharge planning to accomplish the timely transition of patients to a post-hospital setting. Responsible for communicating with external agencies to provide information necessary for utilization/case management purposes. Provides services primarily to Adult and Geriatric patients, and occasionally pediatric patients. Make nursing home, personal home care, mental health, rehabilitation, Hospice, DFACS emergency and financial assistance referrals, and home health and DME referrals. State of Georgia Licensed Social Worker or Registered Professional Nurse required. BSN or MSW preferred. Minimum three (3) years experience in an acute care setting (RN); one (1) year hospital discharge planning/ interviewing and counseling in hospital setting (SW). |
