Provides care coordination for patients across the continuum for a specified episode of care. Coordinates efforts between acute and post acute providers including surgeons, case management, all therapies, physician assistants, skilled nursing facilities, home health care agencies, LTACH's and all other staff involved in this process to coordinate care management activities that will facilitate delivery of high quality, efficient and cost-effective health care services . Facilitates the Integration of evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that promote quality and efficiency in the delivery of health care. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient's health status and health care experience. Engages patients in goal setting and action plan creation to assist patients in achieving optimal health and desired post hospital outcomes. Collaborates with community agencies, physician offices and third party payers to obtain needed services and resources for patients, families, and caregivers. Responsible for reviewing post acute providers documentation, facilitating adherence to established care guidelines and reporting any variance to Case Management (CM) Leadership. Completes and Maintains established transition assessments to establish best level of care, regulatory compliance expectations and outcomes. Collaborates with CM Leadership to design and establish practice improvement changes in an effort to improve care coordination workflow, and provides timely feedback regarding all aspects of barriers encountered.

Minimum Qualifications

1. Master's degree in Social Work from a college or university social work program approved by the Michigan Board of Social Work and accredited by the Council on Social Work Education.

2. Current license as a Licensed Master's Social Worker in the State of Michigan, or current limited license to engage in the practice of social work at the Master's level in the State of Michigan, with full licensure within 3 years from date of hire .

3. Two years of acute hospital experience preferred.

4. Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Compliance policies, and Transition Management.

Skills Required

1. Ability to anticipate and resolve a broad range of issues and concerns on multiple, sometimes unrelated, topics, to determine the need for process development and refinement.

2. Communication and/or interpersonal skills for contact with internal and external customers/stakeholders to obtain and interpret a variety of information based on knowledge of departmental practices, DMC policies and programs and specific technical and regulatory knowledge. Discretion must be exercised in deciding what and how to communicate; conflict resolution skills must be exercised where policy issues are concerned both within the functional area and interdepartmentally. Diplomacy, tact and listening skills are required. Ability to read, interpret and write technical materials.

3. Comprehensive knowledge of acute and post acute care delivery practices and techniques.

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.