<p>Responsibilities & Requirements</p> <p>Responsibilities</p> <ul> <li>Assist the care team by providing leadership in supporting and facilitating coordinated care delivery to patients </li><li>Proactively identify and eliminate barriers to discharge </li><li>Collaborating with the care team to ensure planning for appropriate post-acute care plan and back-up plan. </li></ul> <p>Specific job functions will vary based on assigned area but would include items such as:</p> <ul> <li>Coordinate services for all patients assigned prioritizing moderate and high risk patients with serious, complex or chronic health problems or with psychosocial issues. </li><li>Provide advocacy, information and referral services to patients and families to address their psychosocial needs. </li><li>Assists all patients through the healthcare system by acting as a patient advocate and navigator. </li><li>Promotes clear communication with the care coordination team and caregivers, ensuring awareness regarding patient care coordination plan related to transitions of care. </li><li>Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to organization goals for length of stay, readmissions and patient experience. </li></ul> <p>Job Qualifications</p> <ul> <li>Masters of Social Work </li><li>Current Ohio Social Work license required </li><li>BLS Required </li><li>Clinical experience in health care setting </li><li>Awareness of developmental needs over the age span of infant to elder required. </li><li>Ability to work well in multidisciplinary and independent settings and communicate well (verbal and written) </li><li>Ability to coordinate work effectively with other hospital disciplines. </li><li>Ability to recognize and understand the dynamics of individuals from diverse populations. </li><li>Ability to solve problems through the analysis of information. </li></ul> <p>Overview</p> <p>Kettering Health is a not-for-profit system of 13 medical centers and more than 120 outpatient facilities serving southwest Ohio. We are committed to transforming the health care experience with high-quality care for every stage of life. Our service-oriented mission is in action every day, whether it's by providing care in our facilities, training the next generation of health care professionals, or serving others through international outreach.</p>