Job Description

Collaborative work environment with Brooks Rehabilitation medical staff on behalf of family & team members.

1. Interviews patients/families to obtain data regarding home environment, family relationships, financial resources, health and social histories, in order to address the comprehensive needs of the patients/families. Demonstrates knowledge of age-specific needs in assessing family systems.

2. Orients patients/families to the rehab process and explores options regarding discharge planning, and the need for education and/or referral to community resources and support systems.

3. Provides various levels of case management services when indicated, e.g., emotional support to patients/families which facilitates adaptation to the disability and post rehab planning.

4. Relates a clear understanding of reimbursement/financial resources as applies to discharge planning, to include federal and state assistance programs such as Medicare and Medicaid.

5. Documents interventions and developments in the patient's medical record. Records information in an accurate, timely, and concise manner.

6. Provides follow-up, ongoing monitoring, and intervention as needed to assume implementation of discharge plans, patient/family adjustment.

7. Assists with program evaluation and quality assurance activities through follow-up questionnaires and/or other data.

8. Acts as a liaison between colleagues, other departments and community agencies. Develops and maintains liaisons with local, state, and federal resources.

9. Acts as an advocate for patient rights, needs, and goals. Seeks patient involvement in planning to the greatest extent possible. Involves family/significant other when the patient cannot actively participate in goal setting.

10. Obtains written consent upon release of medical records.

11. Organizes individual workload and sets appropriate priorities based on patients' needs and departmental policies and standards.

12. Fosters positive and professional relationships with patients, families, physicians, staff, and department peers.

13. Supports the interdisciplinary team process by formulating team conference reports and conferring with referral sources, patients, and families.

14. Assumes responsibility for personal computer, various office supplies and equipment.

15. Applies Utilization Review (UR) criteria to assure appropriate continued stay and timely discharges.

16. Provides medical information, treatment plan, goals, and discharge planning to Quality Improvement Organization (QIO) as requested on appeals.

17. Completes MDS Assessment and Care Plans.

18. Review Advance Directives with patients/families and assist with implementation.

19. Participate in care planning for long term care residents and coordinate resources to address their care needs. Seeks resident involvement in planning to the greatest extent possible. Involve family/significant other when the resident cannot actively participate in goal setting.

20. Rotate weekends as needed to assure social service coverage in SNF.

Interdisciplinary Collaboration:

• Collaborates with physicians, therapists, nursing personnel, discharge planners, insurance company representatives, families, patients, and business office to facilitate the management of the rehab process in an efficient and cost effective manner.
• Collaborates with other rehabilitation professionals as a member of the interdisciplinary team by attending weekly team conferences and functioning as the liaison between patient/family, other team members, the SNF, and the payor.
• Collaborates with the medical staff and other rehab team members on behalf of the patient/family to coordinate discharge planning.

Qualifications: Minimum of BS/BA in social work or related field., Masters preferred. Experience in Skilled Nursing Facilities (SNF) desired. Two years minimum of case management experience.

Hours: PRN

Location 6209 Brooks Bartram Drive, Building 100, Jacksonville, FL 32258

Brooks Rehabilitation, a nonprofit headquartered in Jacksonville, Fla., has been a comprehensive system of care for physical rehabilitation for more than 50 years. Ranked by U.S. News & World Report as the No. 1 rehabilitation hospital in Florida and top 20 in the nation, Brooks operates three inpatient hospitals in Florida and is set to expand its reach with a new hospital on Mayo Clinic's Arizona campus in 2026. Through its commitment to innovation, Brooks is at the forefront of cutting-edge research, education and technology advancing the science of rehabilitation. Brooks provides outpatient services in more than 50 locations, offers skilled nursing, home health, assisted living and memory care along with community programs and services to improve the quality of life for people living with physical disabilities.