The Social Worker Case Manager 2 provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting and evaluates the biopsychosocial impact on patients' plans of care. Works 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. Provides coordination of services while acting as a key liaison between patients, families, and the interdisciplinary healthcare team.

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.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.May perform additional duties as assigned.

Additional Requirements

Certification - Basic Life Support - Upon Start; ACM or CCM or CCTSW or N/ASW- CM (ASWCM) or LCSW - Upon StartLicensure - None requiredExperience - 2 years of experience in a clinical care or clinical case management settingEducation - Masters's Degree in Social Work