Care Coordination for Hospitalized individuals and their families. Includes but not limited to:Comprehensive needs and resource assessment, interdisciplinary care planning and problem solving,linking patients and families with community based resources, patient and family education regarding continuum of care and available resources through the transitions of care, patient advocate, utilization management and customer service.

Completion of Comprehensive needs assessments of patients. Identifying barriers to post acute care and discharge. Development of safe discharged plan that bests met the patients need at the appropriate level of care. Customer Service and Service RecoveryEducating patients and family regarding continuum of care.Advocating for patient by networking with insurance companies and vendors of health care services.

PRN Social Worker: Admission Psychosocial Assessments, Needs Assessment, Care Planning, Discharge Planning,Advocacy

Social Worker in a Health Care System Owned long term care facility.Responsibilities included but were not limited to:Completion of Comprehensive needs assessments and Social History. Monitoring and developing a plan of care to meet Psycho/Social Needs. Assessment of appropriateness for discharge and discharge planning. Implementing discharge plan. Maintaining accurate up to date medical records and financial records.Advocating for resident's rights, needs and desires.Attending to customer service issues and service recovery.Assisting families as they deal with having loved ones who need long term care. Providing support as needed.DIscharge planning for short term rehab residents.

Completion of Comprehensive needs assessment for patients.Identifying barriers to community care and discharge.Developing safe discharge plan that best met the need of patients at the appropriate level of care.Advocating for patients with insurance companies, health care vendors and community agencies.Articulate up to the minute documentation in the electronic clinical record.Networking with area professionals.Multi Disciplinary Team member.Statistics entry, reviewing outcomes.