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Cleveland Clinic

Cleveland, Ohio

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UT Houston Hospice and Palliative Medicine Fellowship Program

Houston, Texas

B.E. Smith in partnership with Torrance Memorial Medical Center

Torrance, California

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Fellowship Hospice and Palliative Care

Basking Ridge, New Jersey

OhioHealth

Dublin, Ohio

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Atrium Health

Charlotte, North Carolina

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Tufts Medicine

Boston, Massachusetts

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University of Maryland School of Medicine

Baltimore, Maryland

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University Cancer & Blood Center

Athens, Georgia

HCA HealthONE Presbyterian St. Luke's

Denver, Colorado

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Sarah Bush Lincoln Health Center

Mattoon, Illinois

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Avera

Sioux Falls, South Dakota

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University of Michigan Health System

Ann Arbor, Michigan

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Sentara Health

Virginia Beach, Virginia

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Billings Clinic (health system)

Billings, Montana

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St. Luke’s University Health Network

Coaldale, Pennsylvania

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CHRISTUS Health

San Marcos, Texas

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Duke University Health System

Durham, North Carolina

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Veterans Affairs, Veterans Health Administration

Tomah, Wisconsin

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Clinical Social Worker 2, PRN
Job DescriptionCare Coordination:Screen patients to identify needs and prioritize caseload to identify high risk and rising risk patients.Coordinate with interdisciplinary team to develop, revise, (if necessary due to change in patient progress), and implement appropriate discharge interventions to ensure safety and care coordination.Accepts responsibility for patients' Transitions of Care, coordinating provisions for discharge to including follow-up appointments, home health, community services, transportation, etc., in order to maintain continuity of care on identified high risk patients.Communicate with CRM manager any pertinent findings causing a delay in care coo


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