As a Social Worker Case Manager ll, you will provide discharge planning and continuity of care for assigned patients in the acute and post-acute settings. To help achieve our mission, you will provide/evaluate biopsychosocial impact on patients' plans of care. Your ability to evaluate patients' abilities to progress throughout the continuum of care is of vital importance. Working collaboratively in communication with physicians, nursing and other members of the multidisciplinary care team to effect timely and appropriate patient management and the progression of care plans is essential. Your understanding of pre/post-acute resources is expected. Providing coordination of services while acting as a key Liaison between patients, families and the interdisciplinary healthcare team is essential. Showcasing a working knowledge of and experience in the utilization of management, managed care and payer issues is required.

Job Responsibilities
 

Collaborates with the interdisciplinary care team, patients and families in the assessment/coordination of discharge planning needs, delivery of post-discharge planning needs/services, transition of patients from the hospital to the discharge setting as well as ongoing care in the community. Initiates referrals to clinics, home healthcare, hospice, SNF, acute rehab, LTAC, TCM, medical equipment and supplies as indicated. Refers cases/issues appropriately to resolve barriers to care progression. Documents relevant discharge planning information in medical records according to department standards and/or care management plans. Participates in the assessment of patients' biopsychosocial needs through review of information, personal contact with patients/families and interdisciplinary care team members. Communicates routinely with patients, families, interdisciplinary care team members and other appropriate parties with regard to status of patients' care plans. progress toward treatment goals, identification of concerns and/or problems, problem solving and assisting with conflict resolution when necessary. Ensures that all options available to support a successful transition and elements critical to patients' care plans are documented properly and have been communicated to the patients/families and members of the healthcare team to ensure continuity of care. Seeks consultation from appropriate disciplines and/or community services to assist with the facilitation of discharge and ongoing community care plans. On the basis of preliminary risk screenings, assesses the psychosocial risk factors of patients/families through evaluation of prior functional levels, appropriateness/adequacy of support systems, reaction to illness and ability to cope. Intervenes with patients and families regarding emotional, social and financial consequences of illness and/or disability. Serves as a resource person and provides counseling and interventions related to treatment and end of life decisions. Advocates for the empowerment and independence of patients/families to make autonomous healthcare decisions and access needed healthcare services. Ensures safe care to patients by adhering to policies, procedures and standards within budgetary specifications including time/supply management, productivity and accuracy of practice. Receives referrals for complex patient problem resolution from care team members. Validates discharge criteria for patients/families, alerts of newly identified resources and/or changes in previously identified resources in the community. Performs other duties as assigned.

 

Requirements

Masters Degree in Social Work (MSW) required.

A minimum of two years experience in a clinical care or clinical case management setting required.

Requires certification as an Accredited Case Manager upon start (ACM or CCM or CCTSW or N/ASW-CM (ASWCM) or LCSW).

Advanced oral and written communication skills to effectively and professionally liaise with patients, families and medical staff.

Knowledge of regulatory requirements.

Working knowledge of case management processes, needs assessments, principles of utilization review/quality assurance, discharge planning and reimbursement structures (i.e. Medicare, Medicaid and HMO).

Must understand post-acute care criteria and documents appropriate referrals based on patients' clinical presentation and education needs.

Additional Requirements

 Must be able to work independently.  Will be responsible for cases on medical side of behavioral health units.