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Per Diem Social Worker I

Full/Part Time: Per Diem
Location/Affiliates: The Mount Sinai Hospital
Department: 186 - Social Services
Requisition Number: 14-1645768

Job Description:

This position is in C-PACT (Community-based Preventable Care Team). The goal of the program is to reduce the Hospital's 30-day readmissions of Medicare fee-for-service patients by 20%. C-PACT will provide intensified transitional planning for five-weeks post-discharge for Medicare fee-for-service patients at high risk for readmission. This program is based on existing research about how to help those patients at high risk for readmission stay out of the Hospital.

The role of the C-PACT social worker is to do an enhanced biopsychosocial assessment of both the patient and the family caregiver during the hospitalization; to collaborate with the floor social worker responsible for the discharge and with the interdisciplinary team as needed; to refer appropriate patients to the primary care; to provide regular follow-up phone calls to patients enrolled in the program and to family caregivers, physicians, and/or other service providers as indicated. The social worker is responsible for ensuring that the patient receives timely follow-up with the outpatient primary care physician, including collaborating with the primary care physician as needed to secure an appointment and addressing any barriers to keeping follow-up appointments post-discharge and adhering to the prescribed medication regimen; contacting the patient and family post-discharge and prior to the first follow-up appointment to ensure that the patient attends the post-discharge follow-up appointment as scheduled; and providing on-going phone contact and/or home visits if necessary with the patient and the family to address all issues impacting the potential for preventable readmissions.

Job Qualifications:

New York State LMSW or LCSW required

Exceptional skills in engaging patients and families and in assessment and coordination of resources within families and hospital and community networks for effective management of patient care.

Exceptional organizational, collaborative and psychosocial assessment and intervention skills.

Interest in being part of an innovative initiative to improve the quality of care by addressing preventable readmissions.

Mount Sinai Medical Center is an equal opportunity/affirmative action employer. We recognize the power and importance of a diverse employee population and strongly encourage applicants with various experiences and backgrounds. Mount Sinai Medical Center--An EEO/AA-D/V Employer.

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