| Location | Lebanon, New Hampshire |
Provides assistance to patients/support systems and the multidisciplinary teams to identify, provide information, and facilitate access to tangible and supportive services related to patient health care needs.
Responsibilities:1. Needs Assessment:
• In Collaboration with care team, conduct evaluations of client needs through interviews and assessments
• In Collaboration with care team identify barriers to accessing resources and develop strategies to address them
2. Resource Coordination:
• Connect patients with appropriate services such as housing, healthcare, food assistance, transportation, and employment programs.
• Maintain an up-to-date knowledge of local community resources and eligibility criteria.
• Educate clients on available services and how to access them independently
• Identifies available transportation resources and collaborates with patient/support system for cost effective, safe transportation
3. Advocacy:
• Advocate for patients to have knowledge to support access to resources and services they are entitled to
• Advocates/supports access for patients to skilled, acute or long-term care facilities
4. Compliance and Documentation:
• Delivers Important Message from Medicare/Discharge Rights
• Collaborate to support completion of application process to obtain resources and with completion of Advanced Directive Care Planning
• Document case details in compliance with organizational policies.
5. Collaboration:
• Work closely with social workers, counselors, and other professionals to support discharge planning and care transitions
• Attend inter-disciplinary rounds or unit huddles to strengthen relationships and improve resource access for patients.
6. Administrative Tasks:
• Maintain accurate records and reports.
• Provide communication of resource availability for transitions of care to include unit phone support, e-mail communications, and direct patient meetings
7. Performs other duties as required or assigned.
Qualifications: