Nuvance Health has a network of convenient hospital and outpatient locations - Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York - plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care. Non-acute care is offered through various affiliates,

Summary:
Performs assessments and formulates discharge/transition plans in collaboration with patient, family and multidisciplinary healthcare team. Provides ongoing monitoring and evaluation of plans to meet the individual needs of patients throughout the care continuum. Assists in resource management through facilitation of care and participation in program planning, data collection and analysis. Provides education to patients/families regarding coverage, care options and community resources;

Responsibilities:
1. Care Coordination/Facilitation and Transition Management - coordinates multiple aspects of care to all appropriate patients to ensure the patient progresses through the hospitalization. Makes the transition to the next level of care with the services required to promote high-quality outcomes.
2. Assists in the development of the patient's plan of care and ensures the plan is implemented timely. Discusses with the healthcare team identified delays while providing direction, assistance and support in developing strategies and interventions to move patient through the continuum of care. Follow up on any delays and help expedite diagnostics and treatments.
3. Assesses patient's clinical readiness for transition in collaboration with the healthcare team and informs the team of the available resources based on the patient's clinical needs. Initiate paperwork to transfer information to the community providers timely. Maintains easy flow of communication regarding patient's development and progress to all involved in care of patient.
4. Provides onsite clinical and case management services at Maplewood Assisted Living at Bethel and Newtown locations. Collects collateral information from families and provides care coordination in collaboration with the treating psychiatrist for patients under the physician's care. Provides brief therapy to patients with depression, interventions with families. Training and clinical support of staff as it relates to psychiatric and behavioral issues.
5. Participates in the development and improvement of clinical initiatives focused on reducing LOS, Denials, Re-admissions and ensuring appropriate levels of care. Actively involved in all daily, weekly rounds/meetings. Knowledge of hospital and community resources and is a resource for the healthcare team.
6. Maintains effective relationships and a positive outlook when interfacing with other departments, multidisciplinary healthcare team as well as patient's/families and community providers.
7. Acts as an intermediary between patients, physicians and community providing advocacy, accurate healthcare information, potential referral services and proper treatment plans. Initiates and coordinates patient care conferences as required.
8. Social Work Care Coordinators provide clinical social work interventions which include counseling, bereavement and crisis intervention as well as assessment and intervention in cases involving complex family/patient dynamics.
9. Utilization Review Care Coordinators reviews all admissions and continued stays for assigned group of patients to determine certification to the assigned level of care utilizing standardized criteria to achieve optimal outcomes and reimbursements. Provides timely clinical information to the commercial insurers. Coordinates direct communication between MD's and insurers to proactively avoid denials. Identifies variances, avoidable days, readmission and LOS issues and works with department leadership and the healthcare team to develop changes in process to improve outcomes. Collaborates with other members of care coordination to communicates changes in level of care as well as other pertinent information required for an optimal transition plan. Provides education to patient/families and the healthcare team.
10. High Risk Care Coordinators coordinate care for a group of patients with a specific diagnosis and/or complex discharge needs across the continuum. Provides assistance and support in collaboration with the healthcare team to ensure that patients are given all available resources to meet their healthcare goals and improve self-management of their health/disease process.
11. Maintains confidentiality on relevant issues and information. Takes accountability for personal performance and goal achievement. Takes initiative to set high standards of honesty, integrity and performance for self and others.
12. Collaborates effectively with team members, develops good relationships both inside and outside of the team. Constructively works through problems/issues without becoming defensive or antagonistic. Contributes ideas and supports decisions made by the team and the organization. Always treats others with dignity and respect.
13. In accordance with all regulatory requirements, documents accurately, objectively and timely, the patient's plan of care and discharge disposition.
14. Identifies patient safety and quality issues and reports to appropriate individuals. Uses high reliability principles to ensure patient safety and quality outcomes.
15. Western CT Medical Group Primary Care Offices served: Newtown, Brookfield, Ridgefield, Southbury and Danbury. Facilitates the Behavioral Health integration in primary care as the onsite Behavioral Health LCSW, five hours per week at each location, performing behavioral health assessments, referrals and recommendations for treatment and community services. Western CT Medical Group: Maintains outpatient practice through the Department of Psychiatry. Facilitates behavioral health treatment groups at WCMG and facilitates groups for the Bariatric program.
16. Fulfills all compliance responsibilities related to position, performs all other duties as assigned.
17. Performs other duties as assigned.

Other information:
Required: Broad based clinical background and hospital experience. Excellent oral and written communication skills. Basic computer skills. Prioritize the daily workload and utilize tools dedicated to the position/function. Deal with a high degree of public and patient contact and interaction, and make independent decisions, perform concurrent tasks, manage stressful situations and balance multiple priorities.
Minimum Experience: three years

Desired:

Location: Danbury-24 Hospital Ave

Work Type: Full-Time

Standard Hours: 40.00

FTE: 1.000000

Work Schedule: Day/Eve 8

Work Shift: Variable 7-330, 8-430, 11-7, 230-11; every other weekend (sat and sun) required

Org Unit: 504

Department: DH Inpatient Psych

Exempt: No

Grade: S11

Salary Range:

$32.6400 - $65.0148 Hourly

Credentials:
Essential:
* Licensed Clinical Social Worker

Education:
Essential:
* Master's Level Degree

Working conditions:
Essential:
* Some manual skills / motor coord & finger dexterity
* Little or no potential for occupational risk
* Medium to Heavy effort. May exert up to 35 lbs. force
* Generally pleasant working conditions.
* Little or no manual skills / motor coord & finger dexterity
* Sedentary/light effort. May exert up to 10 lbs. force

EOE, including disability/vets.

We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-739-7330 (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.