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, and two urgent care offices.
Non-acute care is offered through various affiliates, including the
Thompson House for rehabilitation and skilled nursing services, and
the Home Care organizations.
The Care Coordination Social Worker (LMSW) is responsible for
providing counseling, crisis intervention and complex discharge
planning services to assigned inpatients and patients in designated
outpatient areas. Participates in discharge plan design with the
Clinical Care Coordinator on the units or in the ED. Seeks
conservatorships when needed and is knowledgeable about all
available community resources.
Completes assessments as needed and collaborates with the
Clinical Care Coordinator to identify needs and design an
appropriate discharge plan. Manages an assigned group of patients,
including those with complex discharge plans. Implements the plans
and with the Care Coordination Assistants ensures that all services
and equipment and/or transportation are confirmed for day of
discharge. Notifies appropriate members of the healthcare team of
any delay or late day discharges.
Serves as an assigned or on call resource to the POE Clinical
Care Coordinator to identify and implement discharge options in the
ED. Provides counseling to patients/families in crisis, offer
substance abuse counseling and referrals, financial need referrals
and grief counseling. Provide staff support at times of traumatic
loss. Keeps Clinical Care Coordinator informed appropriately.
Provides education to ED.
Maternal/Child Health: Provides grief counseling for fetal
demise, sudden death as well as providing referrals for identified
needs. Participates in MDR's in NICU.
Assesses assigned patients for abuse/neglect, domestic violence,
and reports to appropriate agencies, Clinical Care Coordinators and
other internal departments per protocol. Initiates and coordinates
applications for conservatorships, works with appropriate legal
counsel and courts as needed.
Lead patient and family conferences as needed. Provide Advanced
Directive resources as needed as well as the Patient Right to
Choose information for selection of post-acute hospital care.
If patient has been readmitted within 30 days of discharge,
complete the readmission and CARL tool.
Ensure that Clinical Care Coordinator is informed of any changes
to discharge plan or barriers to a safe and timely discharge.
Fulfills all compliance responsibilities related to the
- Performs other duties as assigned.
Required: Requires a minimum formal education of Master's Degree
in Social Work and a minimum of three years counseling and
discharge planning experience in an acute care hospital or
equivalent, and demonstrated discharge planning and implementation
skills. Analyze financial and social situations, identifying
problems and alternative courses of action. Ability to be flexible,
resourceful and creative in problem solving. Requires a high degree
of prioritization skills. Ability to act independently and offer
suggestions and new ideas for improving performance and operations.
Keeps supervisor, peers, physicians, interdisciplinary team
members, patients and families informed about progress, problems
and developments. Proofread and check documents for errors as well
as the ability to use a keyboard to enter, retrieve, and transform
data. Effectively communicate with physicians, patients, families
and other members of the interdisciplinary team.
Minimum Experience: three years
Desired: Case Management Certification preferred.
Location: Danbury-24 Hospital Ave
Work Type: Full-Time
Standard Hours: 40.00
Work Schedule: Day 8
Work Shift: 9:00am-5:30pm
Org Unit: 152
Department: Care Coordination-DH
- Licensed Master Social Worker
- 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.
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