Position: Coach / Social Worker

Shift: Monday-Friday 8am-4:30pm

Management of clients transitioning from the acute/sub-acute hospital or Skilled Nursing
Facility setting back to their home, or clients identified by health care payor in needed care
coordination, short-term care management, or assessments.
2. Management of clients referred by payor.
3. Understand and complete all requirements to be credentialed in hospital or health care
payor system.
4. Using motivational interviewing, as well as educational and transition coaching tools, to
conduct hospital visits and prepare client for a home visit (as applicable).
5. Prepare for and conduct post-discharge visit in the home within 48 hours of discharge (as
applicable).
6. Perform in-home or telephonic assessment, HomeMeds (as applicable), and create care plan
(as applicable) based on health care contract and scope of work.
7. Perform timely care coordination follow up calls based on intervention being provided.
8. Identify support systems for the client including timeliness of primary care physician visit,
especially after hospitalization.
9. Assist in development of a community-based referral network. Organize, coordinate, and
conduct reviews of community resources and social service agencies and other psychosocial
referral sources for clients.
10. Develop and maintain automated or manual systems and procedures to facilitate on-going
program operations.
11. Participates as an active team member in care transitions with internal and external team
members.
12. Identify, assess, and respond to crisis situations in a timely fashion, with appropriate
interventions.
13. Observe all legal, departmental, health plan and/or hospital regulations.
14. Develop and maintain positive community interactions; build referral relationships in the
community and seek new resources