Transitions Case Manager
Core
Assesses patient appropriateness for admission to a Transitions program, conducts in-home assessments, and coordinates service plans for clients and families.
Role type
Case Manager (Social Work)
Builds
Individualized care plans and service coordination for patients/families
Domain
Healthcare / Social Services / Hospice
Deliverable
client delivery
Required skills
patient assessment, care plan development, community resource referral, data documentation, interpersonal relationship building, oral and written communication
Preferred skills
experience with hospice population
Technologies
database systems
Responsibilities
receiving and scheduling incoming referrals, completing client/family assessments to determine program appropriateness, identifying client needs and setting goals, implementing and coordinating service plans, facilitating ongoing assessments and re-evaluations, referring clients to community services, documenting visits and calls in a database
Seniority
Mid-level IC