As a Licensed Continuing Care Liaison - LICSW, you will be an integral member of a multi-disciplinary health care team that provides continuity of care in transitioning complex care patients from the acute care setting to home.  This role partners with acute care setting interdisciplinary team in identifying patient/family needs and developing the plan of care to successfully transition home and continues to follow the patient, working with home-based care interdisciplinary team to ensure health outcomes are met and patient/family success at home.

1. As an integral member of a multi-disciplinary health care team that provides skilled nursing, rehabilitative care and medical social work to patients, allowing them to receive the medical care required in the comfort of their own home.
2. Accurately document observations, interventions and evaluations pertaining to patient care management and services.
3. Works with discharge planners and referring providers to identify high risk patients and ensure a seamless transition to DHHC services.
4. Provides information and education to prospective patients and families on home-based care services; performs a comprehensive patient/family assessment and in collaboration with the patient, family and care partners, develops a plan of care for transitioning the patient from the acute care center to home; provides continuing support and coordination for patient/family following transition home.
5. Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in transitioning patient’s home.
6. Monitors the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.).
7. Shares assessment and physical, psychological, social and environmental care plan data with patient/family consent as the patient moves through different care settings.
8. Identifies gaps in the care continuum and work with the community and provider networks to expand access to needed physical, psychological, social and environmental services.
9. Participates in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization.
10. Collects and evaluates data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization.

This job description is not meant to be exhaustive and may be modified as needed. Employees may be assigned other related duties to meet organizational needs.

• Masters of Social Work required.
• Minimum one year experience in a health-related field required.
• Collaborative team player, use of systems approach in planning, problem solving and decision making, creativity, innovation, risk taking, autonomy, flexibility, receptiveness to change and a commitment to professional growth desired.
• Understanding of and comfort using computers desired.

• Licensed Independent Clinical Social Worker (LICSW) in New Hampshire and VT Required.
• Valid driver’s license, and a clean driving record
• Current car insurance, which meets minimum standards
• BLS within 90 days of hire