Continuum Of Care Specalist

Department/Unit:

Care Management/Social Work

Work Shift:

Day (United States of America)

Salary Range:

$77,075.00 - $119,466.00

The Continuum of Care Specialist is a master’s level Social Worker (MSW) or RN with Bachelors Degree, BSN preferred.

Nurse Case Manager (CM) who directs care in collaboration with RN and SW staff for multidimensional complex patients across the continuum of care. The position also provides support to CM/SW staff in managing highly complex patient issues to facilitated discharge decision and dispositions.

Qualifications and Ideal Characteristics

• Master’s Degree in Social Work with state licensure or RN with state licensure and Bachelor's  degree, BSN preferred 

• Experience in field of clinical social work or nursing with experience in care transitions, 3-5 years.

• Highly competent in clinical aspects of social work and/or case management role, based on experience and years of work in the field.

• Extensive contacts and work relationships with external continuum of care providers and agencies assisting with difficult patient transitions.

Principal Position Responsibilities

• Demonstrates advanced knowledge and expertise in CMS, DOH, OMH, OPWDD laws and regulations pertaining to access, delivery, transition and financing across continuum of care; expertise with entitlement eligibility, managed care, guardianship, immigration and naturalization laws.

• Acts as an AMC liaison with executive leadership interfacing with continuum of care providers and public agencies including SNF administrators, vendors, CHHA’s, LDSS-APS/CPS, NYS-OMH, OPWDD, MHLS, among other regulatory agencies.

• Provides leadership specific to discharge planning and coaching of MSW and/or CM staff, standardize unit rounds reporting, acute rehabilitation QIT, and is responsible for staff orientation and continued development.

• Develops and implements policy/procedure protocols related to internal and external processes responsive to clinically complex, high-risk patient care populations prone to ED and IP recidivisms and extended LOS.

• Facilitates responses for all patient complaints related to patient status, discharge planning and/or continuum of care access to meet DOH regulatory mandates.

• Facilitates the AMC Complex Case Review Interdisciplinary meeting(s) and serves as an expert in LOS with Senior Executives, removing obstacles, facilitating difficult and complex communication to patients and families including bio-ethic considerations regarding transitions in care.

• Attends AMC bi-weekly Patient Grievance Committee and serves as clinical expert in cases with Patient Relations and senior executives, facilitating complaints with the group to respond to patients and families regarding their grievance filed.

• Responsible for collaboration with Logistics in the back-transfer process and is supportive of the CM/SW team in that process. Participates in Back Transfer rounding meetings

A. Mission, Core Values and Service Excellence

• 1. Contributes to the creation of a compassionate and caring environment for patients, families, and colleagues through displays of kindness and active listening.

• Demonstrates excellence in daily work. Willing to actively participate in performance and quality improvement activities and to work towards enhancing customer/patient satisfaction.

• Exhibits positive service excellence skills to patients, visitors, and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays, and changes.

• Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance.

• Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols.

• Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work time, displaying a consciousness regarding costs, supplies, and department finances.

• Demonstrates respect for individual differences of each person acknowledging the essence of each person, appreciating, and responding to unique, spiritual, personal, and cultural backgrounds of patients, families, and colleagues.

B. Communication Skills

• Within the role create a collegial and collaborative environment as an AMC liaison to all external agencies in the area of care transitions. (Examples: DOH, OMH, guardianship hearings, APS, CPS, all long term care facilities, home care agencies, DME vendors)

C. Professional Skills

• Coaches and mentors staff

• Is an expert in the practice standards of social work and/or case management

• Guides and directs LOS team

• Guides and Assists with Patient Grievance Committee

• Maintains professional demeanor at all times

• Accountable for all actions

D. Reasoning Ability

• Improving job performance through continuing education.

• Has the ability to collect data establish facts, make conclusions

• Rehab weekly report

• Utilizes SW and/or CM productivity data; makes recommendations for changing staff assignments as necessary

Physical Demands
The physical demands described here are representative of those that must be met by an
employee to successfully perform the essential functions of this job.
While performing the duties of this job, the employee is regularly required to stand, walk,
use hands to probe, handle, or feel objects, tools, or controls, reach with hands and arms,
and speak and hear. The employee is occasionally required to sit and stoop, kneel, or
crouch.
The employee must regularly lift and/or move up to 50 pounds. Specific vision abilities
required by this job include close vision, distance vision, peripheral vision, depth
perception, and the ability to adjust focus.

Work Environment
The work environment characteristics described here are representative of those an
employee encounters while performing the essential functions of this job. While
performing the duties of this job, the employee may be subject to infectious materials and
chemicals (see unit specific MSDS information).
The noise level in the work environment is usually moderate.
This job requires as an essential function that the majority of the time the employee be
physically on-site as the work cannot be done from a remote location.

Other Requirements
All job requirements listed indicate the minimum level of knowledge, skills, and/or ability
deemed necessary to perform the job proficiently. This job description is not to be
construed as an exhaustive statement of duties, responsibilities, or requirements.
Employees will be required to perform any other job-related instructions given by their
supervisor subject to reasonable accommodations.

Thank you for your interest in Albany Med Health System!​

Albany Med Health System is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.