Job Description
The Social Work Case Manager in Care Management is a professional clinician that utilizes principles of care coordination to support patients and their families/caregivers.
Collaborating with an interdisciplinary team of providers, clinicians, health plans, and external partners, the incumbent advocates for patients and families/caregivers to coordinate care across the continuum.
This role is integral to the Care Management team, which works to improve the quality of care, patient experience, and the health of populations and individuals by focusing on the social determinants of health impacting wellness.
Essential Responsibilities:
* Comprehensive Assessment and Interventions
o Contributes to and/or completes initial and ongoing comprehensive assessment. Provides interventions and implements recommendations after engaging patients and their caregivers/families. Focuses on the individual's risk related to social determinants of health to assure successful coordination of care across the continuum.
* Transition Planning
o Collaborates to provide the safest transition plan for assigned patients (Inpatient/Observation/ED) in order to ensure a timely discharge and provide appropriate connection with post-discharge care providers and community based resources.
* Patient Education and Advocacy
o Educates patient, family/caregiver and physician regarding most appropriate level of care post discharge and how to access community support. Advocates for the patient, family/caregiver through effectively communicating with interdisciplinary team members, payers and post acute partners to assure the safest transition.
* Treatment Decisions and End-of-Life Issues
o Serves as a resource to provide counseling and intervention related to treatment decisions and end-of-life issues. Drives collaborative conversations to establish goals of care. Provides crisis interventions in cases involving Child Abuse and Neglect, Domestic Violence, Adult and Older Adult Abuse, Institutional Abuse, Sexual Assault, Mental Health Disorders, Substance Use Disorders, and Identification of a Surrogate Decision Maker/Guardianship.
* Professional Growth and Development
o Promotes individual professional growth and development through certification, mentoring/precepting, and/or participation on department/hospital/system committees.
* Department Goals
o Supports Department based goals that contribute to the success of the organization.
Qualifications:
Minimum Qualifications:
* Master's degree in Social Work (Obtain within 6 months of hire)
* Experience in a hospital or health care setting
* LSW required within 1 year of hire. Incumbents in the role on or before 12/31/2022 have until 12/31/2023 to obtain.
* Act 34 Criminal Background Clearance Certificate
* Act 33 Child Abuse Clearance Certificate
* Act 73 FBI Fingerprinting Criminal Background Clearance Certificate.