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About the Role
St. John's Riverside Hospital is seeking a Continuing Care Coordinator to assist in meeting the psychosocial needs of patients and families. This role involves assessing inpatients, screening for continuing care needs, and educating, coordinating, and collaborating with the healthcare team to ensure comprehensive discharge plans. The goal is to ensure appropriate use of resources and facilitate a smooth transition to the next level of care.
Responsibilities
- Assists in meeting the psychosocial needs of patients and families through assessment of inpatients.
- Screens patients for continuing care needs, including emotional support, community resource needs, home care, Sub-acute and Acute Rehab placement, and authorization for inpatient care and aftercare.
- Educates, coordinates, and collaborates with nurses, physicians, case managers, and interdisciplinary team members to assure a comprehensive discharge plan.
- Ensures appropriate use of resources within an appropriate length of stay.
- Collaborates with the multidisciplinary team on the patient’s treatment plan.
- Reviews admissions and continued stays in accordance with establishing discharge plan.
- Reviews assigned units/patients and assesses the patient’s medical, social, financial, and psychological status within three days of patient’s admission.
- Assesses all patients, including those in the Intensive Care Unit, and manages their discharge plan until the patient transfers to another level of care.
- Collaborates, coordinates, and manages the discharge planning needs of assigned patients through assessment and reassessment.
- Reviews cases for quality of care and utilization management issues.
- Assesses patients for discharge planning needs, including substance abusers, homeless and uninsured patients, victims of domestic violence, elder abuse, and child abuse.
- Assesses patients needing referrals for inpatient and outpatient terminal care, inpatient and outpatient psychiatric care, and patients living in assisted living facilities, group homes, and adult homes.
- Is consulted for patients newly diagnosed with cancer for community support services.
- Is consulted for patients who require guardianship and follows through on their discharge plan.
- Is assigned to the Emergency Department for discharge planning as necessary.
Requirements
- Masters required in social work.
- Hospital experience required.
- Able to read, write, speak, and understand the English language.
- Effective professional rapport with physicians, patient, family/visitor, peers and supervisors.
- Sensitivity and Compassion.
- Knowledge of the services of the community, health, welfare, and social agencies.
- Demonstrates flexibility and creativity.
- Must be able to function well under pressure.
- Must have good leadership ability and good judgment.
- Must have good mental and physical health.
- Must be educated in the use of the particulate respirator (mask).
Skills
- LMSW or LCSW preferred.
- New York State Screen Certification preferred.
- Ability to communicate Spanish or community dominant language is desirable.
Location
- Yonkers
- Hastings-on-Hudson
- Ardsley
- Dobbs Ferry
- Irvington
Work Type
- Full-time
Experience Level
- Not specified
Education Level
- Masters
About the Company
- St. John's Riverside Hospital is a leader in providing the highest quality, compassionate health care utilizing the latest, state-of-the-art medical technology.
- Serving the Westchester community from Yonkers to the river town communities of Hastings-on-Hudson, Ardsley, Dobbs Ferry and Irvington, St. John's Riverside has been and continues to be a unique and comprehensive network of medical professionals dedicated to a tradition of service that spans generations.
- St. John’s has been an integral part of the community since the 1890's and its’ commitment to provide the community with the most advanced medical services available continues to be the hospitals’ vision, mission and value.
- St. John's Riverside Hospital built itself around an early foundation of nursing and community service.
- In 1894, the Cochran School of Nursing, the oldest hospital-based school of nursing in the metropolitan area, was founded, thus making the St. John's Nursing Staff more than just the backbone of the hospital, but the heart and soul.
- St. John’s dedicated nurses give superior attention to those who need it most with a strong emphasis on patient and family-focused nursing care.
- St. John’s Riverside Hospital staff is committed to making life better for all patients.
- The hospital continues to elevate the services provided with the goal of increasing the quality of life for all who entrust St. John's Riverside Hospital to their care.
- Personalized care together with advanced technology is what it means to be Community Strong.
Equal Opportunity
- St. John’s Riverside Hospital is an equal opportunity employer.
- We maintain a policy of non-discrimination in providing equal employment to all qualified employees and candidates regardless of race, creed, color, national origin, sex, age, disability, marital status, or other legally protected classification in accordance with applicable federal, state, and local law.