The Complex Care Transitions Coordinator is a LCSW who is responsible for providing a full range of social work services including psychosocial assessment, treatment planning, therapeutic interventions, complex discharge planning, crisis intervention, referral and resource referral. This position assists the patient and family transition to the next appropriate level of care. Under the general direction of the case management director of social services, and in collaboration with case managers, physicians and healthcare team members, evaluates and implements treatment regime for designated patient population. He/She is well versed in patient’s rights regarding care, privacy, safety, confidentiality of medical records, and the Baker Act.
The Complex Care Transitions Coordinator will be responsible for developing and initiating a Complex Patient Care Plan.
The CCTC will initiate and/or participate in patient/family meetings and multidisciplinary team meetings. The CCTC will develop patient specific goals, modify and evaluate plans throughout the patients stay and follow the patient through discharge.
The person in this position works under general supervision, is responsible for various shifts, may be subject to over 40 hours per week and/or callback as required, and may also be required to remain on campus immediately before, during, and after severe weather and/or disasters.