Licensed Clinical Social Worker

Transition Coach-Social Worker

LCSW                                                                                                

Location

New Orleans, LA

LSU Hospital

Company Introduction

Act One Health (AOH) is a population tele-health company that provides physical health management, preventative services, and remote monitoring platform to care for patients in real-time in a new and more effective manner. Our goal coupled with your dedication is to make a difference in our patient’s lives resulting in improving their quality of life.

Position Description
The Transition Coach (TC) serves as a facilitator of care continuity across care settings, coaching the patient and/or caregiver to play an active and informed role in defined care plan.  The TC first interacts with patients in the hospital to ensure a smooth transition home and enrolls the patient into the Transition of Care program. The TC provides guidance to the patient in identifying problems and building relationships with practitioners. The TC focuses on skill transfer beginning discharge day and continuing throughout the 30-day relationship.

Responsibilities
The TC will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the TC is to empower the patient and care giver in the following ways:

• To assert a more active role during discharge and transitions of care from one setting to another and help patient to develop lasting self-management skills.
• Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, and follow-up phone calls after discharge, coordinating services to facilitate timely follow up with care practitioner and understanding red flag symptoms for improved self-management.
• Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs.
• Provide oversight of medication management process, including the patient’s ability to pay for medications and providing adequate support with obtaining medication prior to discharge.

Qualifications

• Current (unencumbered) Social Worker license
• Minimum of 3 years of experience in a medical surgical setting

Skills

• Experience in operating personal computers, including operation of computer software in a Windows environment.
• Must be able to work in a self-directed environment, with ability to work as an integral member of the healthcare team.
• Position requires excellent conflict resolution, problem solving, leadership, and organizational skills, as well as written, and verbal communication skills.
• Ability to communicate effectively with individuals of various educational levels and cultural backgrounds via written and verbal formats.
• Excellent customer service skills and people skills