DEFINITION OF POSITION:

Assesses, develops, implements and monitors a comprehensive plan of care through an interdisciplinary team process in conjunction with the patient and family in internal and external settings. Comprehensively assesses patients' goals as well as their biophysical, psychosocial, environmental, functional, and financial status. Procures services and serves as advocate on behalf of patients and families for scarce resources. Directs families to arrange for services which require patient/family decision and participation. Acts as liaison to post-hospital care providers and community health resources. Communicates continually with patients, families, medical and hospital staff, caregivers, and post hospital resources. Facilitates or provides necessary patient and family education prior to admission, during hospital stay, and after discharge as indicated. Develops and maintains a positive work climate and positive working relationships with patients, families, medical and hospital staff, post hospital care providers and community agencies.

QUALIFICATIONS:

A. EDUCATION:
Required: High School Graduate or Graduate of an accredited school of medicine, social work, nursing or related medical occupation.
Desired: Previous experience with coordinating community resources for post acute
hospitalization care

B. EXPERIENCE:
Required: Previous clinical experience in an acute care setting, or home health setting assessing skilled care needs and equipment and health maintenance resource needs.
Desired: Previous Discharge Planning and/or Case Management experience.

C. LICENSES, CERTIFICATION, AND OR REGISTRATIONS:
Required: Current licensure in the State of Oregon as appropriate for training (MSW). Case Management Certification.

D. EQUIPMENT/TOOLS /WORK AIDS:
Use of telephone, Fax Machine, Photocopier, etc.

E. SPECIALIZED KNOWLEDGE AND SKILLS:
Must demonstrate the knowledge and skills necessary to assess and plan for post-hospital needs appropriate to neonatal, child, adolescent, adult and geriatric patients. Must demonstrate knowledge of the principles of growth of development over the patient's life span, the ability to assess data reflective of the patient's status, and interpret the appropriate information needed to identify each patient's requirements relative to his/her unique needs. These skills and knowledge may be acquired through previous education, training and/or experience.

F. OTHER:
Bilingual and/or English-Spanish speaking preferred. Ability to work with culturally
diverse population.