Social Service & Care Coordinator

Social Services Care Coordinator

Are you looking for an exciting, fast-paced, and challenging opportunity to use your social work assessment skills as well as a service excellence focus to make a difference for our patients and caregivers as aSocial Services Care Coordinator?

Potomac Falls Health and Rehab Centeris currently searching for a dynamicSocial Services Care Coordinatorto join our interdisciplinary team.

Social Services Care Coordinator benefits for our full-time position include:

• Health insurance
• Paid time off
• Dental insurance
• 401(k) with employer matching
• Vision insurance
• Life insurance
• Health savings account
• Employee assistance program

We are looking for a Social Services Care Coordinator to:

• Ensures proper PASRR screening documentation is on file for all patients/residents and makes referrals for Level II screenings as indicated.
• Leads the Interdisciplinary Safe Transitions Meetings for new admissions and documents as appropriate the results of those STM in the patient record.
• Develops with the Interdisciplinary Care Team (IDT) and updates (as needed) a plan of care to address identified needs.
• Provides patient and/or responsible parties with base line care plan summary and documents that the summary was provided in the EMR.
• Participates as an essential member of the center's Interdisciplinary Care Team (IDT) in developing and maintaining a patient centered plan of care addressing patient/resident's identified needs and transition plan (if applicable)
• Coordinates the implementation of the IDT plan of care, ensuring all disciplines are addressing planned interventions to ensure resident/patient's goals are met and a safe transition to the next level of care.
• Responsible for the planning for and coordination of patient/resident's safe transition to next level or site of care.
• Responsible for the timely delivery of NOMNC (Generic and Detailed) & ABN notices for Medicare & Managed Care beneficiaries, explaining the appeal rights of the beneficiaries, as well as the expedited appeal process.
• Assists patient/family in navigating third party payer appeals processes when payer decisions are not aligned with patient/resident/family goals, and/or IDT assessments for care needs or safe transition to another level of care.
• Coordinates the expedited appeal process for Medicare A (traditional) when appeals occur including collection of information for submission to reviewing entity.
• Appropriately notifies State Ombudsman's office of all discharges from center according to CCR policy and federal requirements.
• Completes the first post discharge follow-up call/check and oversees the process for additional follow-up after the initial call as deemed necessary to determine success of transition to community/lower level of care and prevent unnecessary re-hospitalization.
• Executes the annual Medicaid renewal process for appropriate residents. Attends weekly Medicaid pending meetings with Business Office Manager and Administrator.
• Serves as center level contact person for third party payer case manager, assisting Central Managed Care Case Manager in ensuring all needed information is available for meeting patient/resident's goals and a safe transition.
• Completes all required documentation within required time frames based on regulatory requirements and center guidelines; including but not limited to Psychosocial Assessments, BIMs assessments, quarterly progress notes and episodic progress notes to record encounters and follow-up to issues that impact/potentially impact resident/patient psychosocial well-being.
• Complete all appropriate sections of the MDS timely and accurately according to current CMS RAI manual guidance and company procedure, specifically sections C, D, E and Q. Complete triggered Care Area Assessments (Section V/CAAs) and corresponding care plan development.
• Develops, organizes and coordinates available center and community resources to provide the highest quality social services program, while meeting the needs and interests of the residents.
• Establishes and/or implements social services and safe transition programs that reflect goals/objectives of the department, maintaining compliance with state, federal and center guidelines.
• Maintains a positive working relationship with staff, families and all persons or agencies concerned with the well-being of the resident.
• Maintains a positive and effective working relationship with CCR Social Services Care Coordination Specialist and CCR Managed Care Specialist.
• Maintains positive and effective working relationship with Central Managed Care Case Manager, serving as a backup with continued authorizations, documentation, request for changes in levels, communication with managed care case managers, etc.
• Promote and demonstrate a culture of Service Excellence.
• Perform other duties as assigned.

Do you have what it takes as a Social Services Care Coordinator?

• Bachelor's degree in social work or human services, appropriate to resident needsORone year, within the last five years, of supervised social work experience.
• Strong interpersonal and communication skills; both written and verbal.
• Experience using Microsoft office programs (Word, Excel, Adobe and PowerPoint).
• Must be flexible, detail-oriented, ability to multi-task, meet deadlines and be able to make effective decisions and work as part of a service excellence team.
• Demonstrated training in recognizing and assessing the emotional and social as well as the medical social needs of residents. Knowledge of community agencies and resources available to meet those needs.
• Demonstrated knowledge of third party payer requirements for skilled patients and long term residents.

Because the safety and well-being of our patients and caregivers is so important, Covid-19 vaccination is required.

Come work in a safe environment and be part of a team that is driven by our mission:to provide peace of mind to those we care for: our patients, residents, families and staff.Help us deliver exceptional patient and employee experiences.