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Job Summary: The Social Worker Case Manager coordinates, facilitates, and executes Social Work functions with the patient population through effective collaboration and communication with the Interdisciplinary Care Transitions (ICT) team members.Â Follows patients throughout the care continuum, identifying and addressing psychosocial needs. Provides ongoing support and expertise through specialized application of assessment, individual treatment plans, continuous evaluation of treatment planning, case management, mediation, referral, consultation, education, and advocacy. Enhances the quality of patient management and satisfaction to promote continuity of care through the integration of the functions of case management, discharge planning, and the application of social work practices. Acts as a patient advocate, investigates and reports adverse occurrences, performs staff education related to discharge planning and psychosocial aspects of healthcare delivery. Advocates for the understanding of significant physical, biological, psychological, emotional, and environmental factors underlying patient's health issues.
Coordinates psychosocial activities with the Interdisciplinary Team and Physicians to provide comprehensive discharge planning for each patient. Utilizes critical thinking to develop and execute effective discharge planning.
Remains current from a knowledge base perspective regarding community resources, case management, psychosocial and legal issues that affect patients and providers of care.
Conducts comprehensive, ongoing biopsychosocial assessments of patients and family to provide timely and safe discharge planning.
Serves as a patient advocate.Â Enhances a collaborative relationship to maximize the patientâ€™s and familyâ€™s ability to make informed decisions.
Participates in interdisciplinary patient care rounds and/or conferences.
Provides patient and family education on identified post hospital needs.
Collaborates with clinical staff in the development and execution of the plan of care, and achievement of goals.
Provides education to patients/families and the healthcare team as needed regarding cultural/religious beliefs, ethics, abuse, neglect and financial exploitation, age specific information, patient rights and responsibilities, and advance directives.
Makes referrals to specific community resources that are appropriate in meeting the needs of the patient and/or family.
Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate psychosocial support to the patient population served.
Coordinates the provision of social services to patients, families, and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from health care services.
Serves on Division and Hospital committees when requested.
Arranges for discharge and post-hospital care of patients through institutions and agencies within the community.
Graduate of an accredited program. Master of Social Work preferred.
Social Work License as required by state.
Certification in Case Management preferred.
Three years of experience in healthcare setting.
Prefer prior experience in case management or discharge planning.
Knowledge of government and non-government payor practices, regulations, standards and reimbursement.
Knowledge of Medicare benefits and insurance processes and contracts.
Knowledge of accreditation standards and compliance requirements.
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