Hospice Referral Coordinator Social Worker

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.  

The Hospice Social Worker acts as a member of the interdisciplinary team for the assigned functions related to the coordination of services with internal and external referral sources. You will be responsible for processing inpatient referrals into hospice, ensuring continuity of care and coordinating discharge planning in contract facilities.  The Social Worker also provides assessment, planning and direct patient care to hospice patients in accordance with the agency policies and procedures and the plan of care established by the interdisciplinary team. It will be your goal to keep patients comfortable and provide symptom management. 

A caregiver in this position works days, 8:00am—4:30pm. Every 4th weekend is required. This is a traveling position, which requires floating to all our east region hospitals (Euclid, South Pointe, Hillcrest, etc.).  

A caregiver who excels in this role will:  

• Engage and educate potential customers about the benefits and appropriateness of hospice care.  

• Ensure the patient and his/her family have adequate knowledge and understanding of the hospice benefit.  

• Process inquiries for all new referrals (internal and external). 

• Ensure seamless transition from hospital to the community setting by coordinating the following hospice services at time of discharge:  

• Ordering supplies and DME, 

• Hand-off communication with field team, and 

• Documentation in the electronic medical record 

• Perform and document an initial assessment within three days of admission, utilizing interview, observation and other available information. 

• Establish plan of care for patients and documents intervention within three days of admission. 

• Visit/contact each patient and family according to established plan of care. 

• Implements the established plan of care with each visit. 

• Perform daily assessment and coordinate the plan of care with in-patient staff for General Inpatients (GIP).   

• Assess patient for safety risks, abuse and neglect. 

• Evaluate the patient and family and provide appropriate intervention with each visit. 

• Revise/update patient care plan at each visit/contact based on change in patient condition/status or response and evaluation/effectiveness of interventions. 

• Counsel patients/families/caregivers as needed in relationship to stress and other identified coping issues. 

• Assume responsibility for coordination of care for managing a caseload of patients in the inpatient setting. 

Minimum qualifications for the ideal future caregiver include:  

• Master's Degree in Social Work from an accredited school of Social Work (CSWE) 

• Current Licensure as a Social Worker (LSW) in the State of Ohio 

• Two years of varied work experience as a Master’s prepared Social Worker 

• Current Basic Life Support (BLS) certification through the American Heart Association (AHA) or the American Red Cross 

• Knowledgeable regarding JCAHO and Medicare standards and regulations 

• Can build relationships with patients, physicians, community agencies and institutions while providing excellent customer service 

Preferred qualifications for the ideal future caregiver include:  

• Hospice experience