Investigates, assesses, and plans interventions to help patients cope with social, emotional, economic, and environmental problems. Makes referrals to community agencies providing needed resources. Assists physicians with discharge and follow-up planning, including transfers to other institutions under the guidance of degreed social worker
Reports to: Director - Case Management
Interviews and assesses patients and/or patient's family, caregivers, and/or legal representatives.
Determines, prioritizes, provides and/or arranges for needed internal and external services/interventions.
Participates in case reviews to evaluate case management and progress. Consults with healthcare team members to promote, monitor, and evaluate compliance with patient's treatment plan.
Assists with discharge planning and processes. Identifies appropriate resources, including transportation, housing, healthcare, and social/spiritual services, and provides referrals as part of the discharge plan.