Responsibilities

• Assist the care team by providing leadership in supporting and facilitating coordinated care delivery to patients
• Proactively identify and eliminate barriers to discharge
• Collaborating with the care team to ensure planning for appropriate post-acute care plan and back-up plan. 

Specific job functions will vary based on assigned area but would include items such as:

• Coordinate services for all patients assigned prioritizing moderate and high risk patients with serious, complex or chronic health problems or with psychosocial issues.
• Provide advocacy, information and referral services to patients and families to address their psychosocial needs.
• Assists all patients through the healthcare system by acting as a patient advocate and navigator.
• Promotes clear communication with the care coordination team and caregivers, ensuring awareness regarding patient care coordination plan related to transitions of care.
• 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.

Job Qualifications

• Masters of Social Work 
• Current Ohio Social Work license required
• BLS Required
• Clinical experience in health care setting
• Awareness of developmental needs over the age span of infant to elder required.
• Ability to work well in multidisciplinary and independent settings and communicate well (verbal and written)
• Ability to coordinate work effectively with other hospital disciplines.
• Ability to recognize and understand the dynamics of individuals from diverse populations.
• Ability to solve problems through the analysis of information.

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.