Skilled nursing facility - Responsibilities for this position include but are not limited to the following:
Discharge planning and contributing to the patient's treatment plan. Understanding the patients’ needs of social, psychological and/or environmental needs related to the impact of illness and understanding the patient's need for hospitalization. Coordinating the discharge planning process to ensure a safe and timely transition from hospital to home, community, or institutional setting.
Collaborating and cooperating with other members of the interdisciplinary health care team to ensure continuity of care. Identifying and attending to the psychological needs of patients and families. Providing counseling to patients, families and groups. Documentation in medical record, statistics and reports as required. Facilitating legal matters, financial entitlements and complying with grants and contracts when applicable. Maintaining relationships with community agencies and keeping up to date on resources