Clinical Care Coordinator

Job Description

Job DescriptionSalary: $23.87

BASIC FUNCTION:

Conducts psychosocial assessment of patients and families upon receiving a referral to the Care Collaboration Unit. Establishes goals to assist patients in dealing with unmet medical needs and identify problems. When needed provides crisis intervention to patient and family with appropriate linkage to services. Empowers patients and families to discuss with the medical providers issues that may affect health and wellness.

GENERAL RESPONSIBILTY:

1. Provides holistic care to patients by completing a psychosocial assessment of needs incorporating spirituality.
2. Assist patients with goals and objectives, encouraging ownership of their health and wellness.
3. Identify and discuss barriers and issues that may affect health and wellness.
4. Assist patients and families with navigating complex medical systems, scheduling appointments, requesting referrals and arranging transportation.
5. Collaborate with hospital and nursing home social workers ensuring patients are provided with a safe discharge and continuity of care.
6. Attend care plan meetings at nursing homes with patients and family members to discuss goals and progress towards potential discharge.
7. Provide medical advocacy to complex patients with multiple comorbidities.
8. Provide support to patients and families needed to cope with chronic illnesses. Provide education and assist with referrals for other services.
9. Collaborate with other professionals to evaluate patients medical or physical condition and to assist patient needs.
10. Educate patients on chronic and terminal illnesses discussing options for end of life care. Discuss end of life choices, decision-making, and resources including hospice care, living wills/advance directives/healthcare proxy/MOLST and grief counseling.
11. Assist patient with navigation of medical system upon referral for organ transplant. Work closely with hospital staff to assure patient compliance with treatment plan for committee review.
12. Records medical social work activities and prepares reports as required.
13. Must be able to travel between clinic locations and local community agencies/providers. This can include travel during inclement weather.
    
14. Follows all established SNHS policies.
15. Performs other duties as assigned.

MINIMUM QUALIFICATIONS:

Masters degree from an accredited school of Social Work, Human Services, Counseling, Public Health or related field. Candidate must have a minimum of 1-3 years experience in developing and implementing health promotion, disease prevention programs. Valid NYS drivers license required. Excellent oral and written communication skills, including public speaking. Highly organized, with the ability to develop organizational tools and track data. Excellent computer skills including word processing, email, internet, spreadsheet and database usage.

PHYSICAL DEMANDS:

Position requires employee to use a computer for extended periods of time. Demands of the job also include but not limited to sitting, standing, driving, listening, observing, cleaning, writing, talking, ability to bend/pivot at waist (standing or sitting), lifting or reaching above/below shoulder height. Light/Medium lifting.