The incumbent provides support to the Patient-Aligned Care Team (PACT) for challenging patient-care situations. The Social Worker's role is to address the Veteran's bio-psychosocial needs, eliminate barriers to healthcare interventions, coordinate care across specialty areas and care settings, provide Veteran/caregiver and family education and support, and coordinate resources to assure comprehensiveness and avoid duplication. Independently performs case finding functions and outreach, identifying and screening patients for psychosocial needs. Identifies high-risk cohorts through collaboration with interdisciplinary team for early intervention to prevent inpatient stays. Collaborates with inpatient social worker when high-risk patients are admitted and in disch
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Case Management Society of America 5034A Thoroughbred Lane Brentwood, TN 37027