20 HOURS PER WEEK

Provides assistance to patients/support systems and the multidisciplinary teams to identify, provide information, and facilitate access to tangible and supportive services related to patient health care needs.

1. 1. Needs Assessment:• In Collaboration with care team, conduct evaluations of client needs through interviews and assessments• In Collaboration with care team identify barriers to accessing resources and develop strategies to address them 2. Resource Coordination:• Connect patients with appropriate services such as housing, healthcare, food assistance, transportation, and employment programs.• Maintain an up-to-date knowledge of local community resources and eligibility criteria.• Educate clients on available services and how to access them independently• Identifies available transportation resources and collaborates with patient/support system for cost effective, safe transportation 3. Advocacy:• Advocate for patients to have knowledge to support access to resources and services they are entitled to• Advocates/supports access for patients to skilled, acute or long-term care facilities 4. Compliance and Documentation:• Delivers Important Message from Medicare/Discharge Rights• Collaborate to support completion of application process to obtain resources and with completion of Advanced Directive Care Planning • Document case details in compliance with organizational policies. 5. Collaboration:• Work closely with social workers, counselors, and other professionals to support discharge planning and care transitions • Attend inter-disciplinary rounds or unit huddles to strengthen relationships and improve resource access for patients. 6. Administrative Tasks:• Maintain accurate records and reports.• Provide communication of resource availability for transitions of care to include unit phone support, e-mail communications, and direct patient meetings 7. Performs other duties as required or assigned.

• Bachelor's degree in Social Work or Human Service field or the equivalent in education and experience required.
• Excellent interpersonal, communication, and organizational skills required.

• None