At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. **Primary Function/General Purpose of Position** The SW Care Manager (SW-CM) is a key contributor to the overall financial and customer satisfaction performance at St. Francis Health system. The SW-CM is accountable for the development and implementation of discharge plans for inpatients. Incorporated in this process are monitoring and evaluation of care to ensure care is medically necessary, provided in the most appropriate setting and generated according to governmental and regulatory agency standards. Responsible for the timely coordination of social work services to assist individuals and their families in addressing social, emotional and economic stresses associated with illness or injury. Support an outcomes oriented patient care delivery system, which places the patient at the center of all activities. Provide patients/families with concurrent information regarding diagnoses, treatment plans and discharge plans. Perform psychosocial assessments to identify high risk cases and initiates referrals to promote independence and the ability to care for oneself. Identification of potential quality of care issues and reporting of variances through the Performance Improvement Program. **Employment Qualifications** **Education** : Bachelor degree from a school of social work or social welfare accredited by the Council on Social Work Education and/or licensed by the South Carolina State Board of Social Work, Masters Degree preferred. Minimum of three years experience in clinical social work activities in an acute care facility preferred; minimum of three years experience in social work role required. **Skills:** Trained in the principles and practices of social work. Able to assess data reflective of the patient’s status and interpret appropriate information needed to identify each patient’s requirements for care relative to his or her age-specific and cultural specific needs. Knowledgeable of discharge planning, including home health care, adoption, home bound schooling, placement in foster homes, assisted living, subacute, rehabilitation, hospice, and long term care facilities and all available community resources. Demonstrate the ability to counsel patients and families regarding financial assistance and community services. Knowledgeable of regulatory/accrediting agency requirements, including Child and Adult Protective Services and the Omnibus Adult Protection Act. Exhibit communication skills which encompass the ability to: + Obtain and interpret information appropriate to patient age, cultural background and level of education and comprehension; + Provide constructive feedback and convey a caring attitude; + Coordinate care between clinical specialties, medical staff and community agencies for safe and appropriate discharge planning; + Coordinate care to support cultural, ethical and religious beliefs; + Formulate and logically convey ideas while being sensitive to the needs and feelings of others; and + Encompass critical thinking, decision making and the ability to help patients/families maintain independence for health care decisions. + Demonstrate good to excellent computer skills and become proficient in navigation of the electronic medical record (ConnectCare®) and master EnsoCare-CareFinder Pro for all discharge planning referral activity. **Essential Job Functions** Conduct an objective assessment of the patient’s current health care status and document such in the patient’s medical record within 24 – 48 hours of admission, including a situational analysis and functional assessment covering elements such as: + Reason for entry into the system; + Physical condition; + Age; + Psychological assessment; + Social/family assessment; + Spiritual assessment; + Financial assessment; + Vocational assessment; + Primary caregiver availability; + Learning capabilities/self-care; + Health status expectation; and + Community reintegration potential. Utilize data from the situational analysis, functional assessment, clinical review criteria and the electronic medical record (ConnectCare®) to identify and prioritize patient care needs in preparation for discharge. Participate with the development/expansion of the plan of care to encompass multi-disciplinary patient care needs within one business day of admission as appropriate for identified discharge needs. Participate with the revision of the plan of care every 48 – 72 hours and document any revision of the discharge plan in the patient’s medical record. Facilitate multi-disciplinary plan of care meetings to maintain rapport and communication with the treatment team to monitor and evaluate the plan of care and patient discharge plan; identify/prioritize problems and make adjustments as required. In accordance with the South Carolina Social Work Practice Act (Title 40 – Professions and Occupations, Chapter 63, Section 40-63-10 § 23-26) The Social Work Care Manager (LBSW, LMSW and LISW), according to the practice of “Care Management” may write physician telephone and/or verbal orders related to discharge planning to facilitate timely execution of the patient discharge plan. The Physician will co-sign all Social Work orders. All orders are to be entered into the electronic medical record ConnectCare®. Demonstrate leadership by initiating referrals to community agencies as needs are assessed (Adult/Child Protective Services, Med Assist, American Cancer Society, DSS etc …). Set goals and time frames for achievement of goals that are appropriate to the patient, family, physician and other members of the health care team. Communicate patient care interventions in writing. Routinely evaluate progress towards the attainment of goals, and request Palliative Care intervention to assist with care management and expedite the discharge. Maintain rapport and communication with the patient/family to provide concurrent information regarding diagnostic testing, treatment plans and discharge plans. Document patient/family education via the Interdisciplinary Patient Education Record in ConnectCare®. Participate in the development, implementation and evaluation of clinical pathways. If the case is static or regressive, determine the reason and make appropriate adjustments. Active participation in interdisciplinary rounds at bedside and identify barriers to discharge and communicate those barriers to the Care Team. If the prognosis is poor, or the case is anticipated to be terminal, direct care towards maintenance of comfort and request palliative care intervention as appropriate. Utilize proactive triggers (diagnoses, readmission and patient satisfaction scores) to identify potential over/underutilization of services and make suggestions as appropriate. Monitor and evaluate the quality of care provided. Report variances through the Performance Improvement Program. Recommend and facilitate transfer/discharge to lower acuity units or settings as appropriate. Collaborate with RN Care Manager, hospital staff and medical staff to direct care toward predictable outcomes. Review discharge plan every 48 – 72 hours and document in patient’s medical record via Case management one stop in ConnectCare®. Prevent readmission by linking the patient/family with the most appropriate institutional or community resources; develop new resources if gaps exist within the health care continuum. Provide communication and knowledge of benefits to patients and physicians before expenses are incurred. Educate hospital and medical staff regarding Care Management/discharge planning issues. Evaluate post discharge needs and safety/appropriateness and adequacy of discharge planning. Social Workers may have access to storage areas with minimal risk medications while performing job duties as assigned. **Other Job Functions** Perform duties and responsibilities in an ethical and responsible manner. Serve as a champion to assist medical and hospital staff to understand the principles of case management. Is self-directed and seeks opportunities to expand knowledge. Develop and foster an environment for success through team participation. Adhere to St. Francis rules, regulations and policies Attend all necessary ConnectCare® training to maintain position duties Perform other duties as assigned. _Include a list of other marginal job duties that the employee may perform but which are not essential to the position. These are functions that could be reassigned if necessary._ **Working Conditions** Frequently subject to the following: + Long, irregular hours: + Varying and unpredictable stressful situations; + Fluctuations in caseloads and patient types; + Performance of duties under public scrutiny; and + Constant interaction with patients, families, visitors, hospital staff, medical staff and community agencies. + Frequent sitting and walking. + Occasional standing, bending and lifting of materials up to twenty (20) pounds. + Frequent communication of information via telephone and computer. + Constant use of vision, frequent reading of written documents and online data. + Constant manual dexterity (grasping, handling, reading, fingering and feeling). + Constant hearing normal speech, hearing on the telephone, talking in person and on the telephone. Many of our opportunities reward* your hard work with: Comprehensive, affordable medical, dental and vision plans Prescription drug coverage Flexible spending accounts Life insurance w/AD&D Employer contributions to retirement savings plan when eligible Paid time off Educational Assistance And much more *Benefits offerings vary according to employment status All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com . If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com