- Patient and family assessment is conducted per established guidelines.
- An individualized longitudinal plan of care is developed in collaboration with the interdisciplinary team, patient, and family, and community providers to maximize quality and cost-effective outcomes while incorporating patient and family goals, expectations, and preferences.
- Education is provided to the patient, family, and the interdisciplinary team regarding community resources and insurance benefits to support the most effective use of these resources to promote maximize and maintain independence.
- Advocacy is provided to meet the comprehensive needs of the patient and family and to promote quality cost effective outcomes.
- Assistance with income replacement, health insurance, transportation, and referrals to appropriate and available community resources is provided.
- Communication and coordination is actively promoted between members of the interdisciplinary team, the payer and the community to minimize fragmentation of services and to maximize outcomes; patient centered team meetings are planned and conducted when indicated.
- Assistance with problem-solving and availability as a resource to the outpatient clinicians is provided.
- Culturally competent care is displayed to identify the patient's cultural needs and incorporate them in the development of the longitudinal plan of care.
- Documentation is completed in adherence to department standards.
- Additional department, organization, or network activities are completed per established objectives.
Care Coordinator - Boston, United States - Brigham and Women's Hospital
Description
Job Description - Care Coordinator (LCSWSummary
Work directly with pediatric patients (and their families) in the outpatient setting who are injured, ill, or newly diagnosed with a pediatric condition and who may experience altering changes in income, health insurance coverage, physical access to their home, specialized transportation, and caregiver assistance to maximize independent function in the community.
Collaborate across the continuum of care and with the interdisciplinary inpatient and outpatient rehabilitation teams, community providers, and community agencies to promote the highest level of independent function and an active, productive and fulfilling life.
Direct and assist patients and their families in the application process for federal, state, and private resources and provide access to specialized disability community resources.
Key ResponsibilitiesQualifications and Experience
Education/Degree
Required
Bachelor's degree required; concentration in
health or human services discipline.
Preferred
Masters degree from an accredited school
Experience
Required
·
Case management, utilization review, or discharge planning experience in an acute, rehabilitation, skilled nursing or outpatient setting is required.
Preferred
·
5 years of related pediatric experience is preferred
·
Certification in Case Management is preferred
Licensure
Required
Current, unrestricted license to practice in Massachusetts in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline.
Examples are Nursing, Physical Therapy, Occupational Therapy, Speech/Language Pathology, LCSW, Respiratory Therapist or Rehabilitation Counselor.LCSW, or LICSW
Preferred
Skills
(Specific learned activity gained through training (e.g. computer skills, keyboarding, presentation, CPR, ACLS,
etc.)
Required
Knowledge of community services and the healthcare systems required
Knowledge of criteria and levels of care is required
Access to reliable transportation to travel to pediatric outpatient sites across the Spaulding Network as necessary
Computer proficiency required. Microsoft office applications preferred with ability to learn new software.
Knowledge of community services and the healthcare system is required.
Preferred
Highly developed communications and interpersonal skills, working with diverse population.
Work independently, be self-directed and contribute as a member of a team.
Anticipates challenges and develops and implements strategies for addressing them.
High level of service delivery. Demonstrate initiative with ability to prioritize work, meet deadlines and adapt to changing situations.
Qualifications and Experience
Education/Degree
Required
Bachelor's degree required; concentration in
health or human services discipline.
Preferred
Masters degree from an accredited school
Experience
Required
·
Case management, utilization review, or discharge planning experience in an acute, rehabilitation, skilled nursing or outpatient setting is required.
Preferred
·
5 years of related pediatric experience is preferred
·
Certification in Case Management is preferred
Licensure
Required
Current, unrestricted license to practice in Massachusetts in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline.
Examples are Nursing, Physical Therapy, Occupational Therapy, Speech/Language Pathology, LCSW, Respiratory Therapist or Rehabilitation Counselor.LCSW, or LICSW
Preferred
Skills
(Specific learned activity gained through training (e.g. computer skills, keyboarding, presentation, CPR, ACLS,
etc.)
Required
Knowledge of community services and the healthcare systems required
Knowledge of criteria and levels of care is required
Access to reliable transportation to travel to pediatric outpatient sites across the Spaulding Network as necessary
Computer proficiency required. Microsoft office applications preferred with ability to learn new software.
Knowledge of community services and the healthcare system is required.
Preferred
Highly developed communications and interpersonal skills, working with diverse population.
Work independently, be self-directed and contribute as a member of a team.
Anticipates challenges and develops and implements strategies for addressing them.
High level of service delivery. Demonstrate initiative with ability to prioritize work, meet deadlines and adapt to changing situations.
Attention to detail
Bilingual
SRN is committed to diversity inthe workplace which begins with respect and opportunity for all.
SRN takesaffirmative action to ensure that equal employment opportunity is provided toall persons regardless of race, religious creed, color, national origin, sex,sexual orientation, gender identity, genetic information, age, ancestry,veteran status, disability or any other basis that would be inconsistent withany applicable ordinance or law.
Primary LocationPrimary Location
MA-Charlestown-SRH Spaulding Rehabilitation Hospital Boston
Other Locations
Work Locations
SRH Spaulding Rehabilitation Hospital Boston
300 1st Avenue
Charlestown
02129
Job
Job
Social Services/Mental Health - Other
Organization
Organization
Spaulding Hospital–Boston & Cambridge(SRN,SRH,SHC)
Schedule
Schedule
Full-time
Standard Hours
40
Shift
Shift
Day Job
Employee Status
Employee Status
Regular
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