Responds to referrals by assessing and providing resources to patients at high risk for complex psychosocial needs. Identifies appropriate financial and community resources to meet the patient needs in collaboration with the Clinical Care Coordinator. Obtains and coordinates existing resources to meet the patient needs, not available via usual services. Serves as a liaison between patient/family and agencies/community services. Such patients may include but not limited to the following which require appropriate intervention and discharge planning.
Completes psychosocial assessment, as the need is determined by the Clinical Care Coordinator clinical assessment.
Participates in intra departmental service teams, task forces, committees, and Performance Improvement teams.
Identifies situations requiring Manager or Director intervention.
Addresses advance directives and end of life issues and facilities completion of appropriate documentation relates to patient decisions.
Job Requirements:
Must have MSW, previous case management experience and hospital experience preferred. Must have computer skills and ECIN software skills preferred.
Responds to referrals by assessing and providing resources to patients at high risk
for complex psychosocial needs. Identifies appropriate financial and community
resources to meet the patient needs in collaboration with the RN Case Manager.
Obtains and coordinates existing resources to meet the patient needs, not available
via usual services. Serves as a liaison between patient/family and agencies/community
services. Such patients may include but not limited to the following which require
appropriate intervention and discharge planning:
* Physical/Substance Abuse.
* Domestic Violence
* Financial Issues (Social Security/Disability Issues)
* Admission to Nursing/Retirement Facility
* Linkage to legal services
* Support group referral/facilitation
* Adoption
* Adult/Child Protection
* Tutoring
* Dysfunctional Family Systems
* Baker Act Placements
* Guardianship referrals
* Hospice referrals
* Indigent patient referrals
* VA Hospital Referrals and transfers
* SNF/ALF- referrals and transfers
* Home Healthcare
Completes psychosocial assessment, as the need is determined by the Nurse Case
Manager clinical assessment.
* Provides counseling, emotional support, and education regarding adjustment ti illness.
* Prepares the family for the reality of caring for the patient on an on-going basis.
* Advocates for the patient's rights and entitlement.
* Participates in team/family conferences giving necessary emotional and social information
to the team. Requests ethics consultation, as required.
Participates in intra departmental service teams, task forces, committees, and
Performance Improvement teams.
Identifies situations requiring Manager or Director intervention.
Addresses advance directives and end of life issues and facilities completion of
appropriate documentation relates to patient decisions.
Maintains competency and participates in continuing education workshops and seminars
pertinent to new regulations, resources and process improvement.
Provides on-call services after regular business hours of the Department in order to
assure coverage of any patient emergencies including abuse.
Demonstrate the application of ECIN utilization for discharge planning and referrals.
* Documents 100% of discharge planning and patient referrals utilizing ECIN software.
* Generate a discharge packet for each patient/family providing information for the
discharge plan.
* Close referrals consistently.
* Print 100% of clinical documentation and place in patient's medical record under the Case
Management tab.
Demonstrates the application of Canopy Software utilization.
* Print 100% of clinical documentation and place in patient's medical record.
Minimum Qualifications
* Bachelors Degree is required; Graduate of an accredited school of Social Work with a
Masters Degree is highly preferred.
* Minimum of two (2) years clinical experience in an acute care hospital or community
service setting is necessary.
* Leadership, communication, and teaching abilities are necessary
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.