Job Type:
Full Time
Job Details
Continuing Care Manager - Social Worker (full-time) in the Lebanon, NH area.
Employer type: Acute care.
What the work involves:
- Manages and coordinates interdisciplinary care of defined populations through the care continuum from wellness through end of life from a psychological, social and environmental perspective.
- Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in regards to psychological, social and environmental areas.
- Monitors the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.).
- Shares assessment and psychological, social and environmental care plan data with patient/family consent as the patient moves through different care settings.
- Identifies gaps in the care continuum and work with the community and provider networks to expand access to needed psychological, social and environmental services.
- Participates in the development of disease management strategies and identifies the appropriate measures for the evaluation of outcomes.
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