LICSW) - Transitions of Care

UHS•Washington, DC

22h•Onsite

About The Position

Cedar Hill Regional Medical Center GW Health is seeking an experienced Registered Nurse (RN) or Social Worker (LCSW/LICSW) - Transitions of Care (Full-Time). The Registered Nurse (RN) or Social Worker (LCSW/LICSW) Case Manager is responsible for the assessment, planning, implementation, coordination, monitoring and evaluation of the patient’s plan of care from admission to post-discharge. The Case Manager utilizes clinical knowledge, critical thinking skills, and the principles of case management to coordinate and implement a discharge plan that meets the patient’s needs and ensures a seamless, effective and efficient transition of care across the continuum. The Case Manager coordinates, negotiates, manages and implements the care of complex patients to facilitate achievement of quality and cost-effective patient outcomes. Works collaboratively with interdisciplinary staff internal and external to the organization. Participates in quality improvement and evaluation processes related to the management of care. Our ideal candidate will be responsible for the overall delivery and quality of patient care provided in the designated area(s) of responsibility. The manager assists with developing and implementing performance initiatives, ensuring optimal patient safety outcomes, and customer satisfaction. This position responsibilities include managing daily work activities, ensuring quality, productivity and efficiency while assisting in accomplishing strategic and operational objectives.

Requirements

Master’s degree in social work (MSW).
Licensed Independent Clinical Social Worker (LICSW) or certification as a Social Worker (LCSW preferred).
Strong understanding of healthcare regulations related to discharge planning (CMS guidelines).
Excellent interpersonal skills with the ability to build rapport with diverse populations.
Proven ability to work independently while effectively collaborating within a multidisciplinary team setting.
Strong organizational skills with attention to detail in documentation practices.
Valid DC RN license.
2 years of acute care experience required.
Current Basic Life Support (BLS) certification required
Strong clinical assessment and critical thinking skills
Excellent communication and interpersonal skills

Nice To Haves

Bachelor's degree in Nursing (BSN) preferred.
Advanced Cardiovascular Life Support (ACLS) certification preferred
Experience in crisis intervention techniques is highly desirable.

Responsibilities

Assessment, planning, implementation, coordination, monitoring and evaluation of the patient’s plan of care from admission to post-discharge.
Utilizes clinical knowledge, critical thinking skills, and the principles of case management to coordinate and implement a discharge plan that meets the patient’s needs and ensures a seamless, effective and efficient transition of care across the continuum.
Coordinates, negotiates, manages and implements the care of complex patients to facilitate achievement of quality and cost-effective patient outcomes.
Works collaboratively with interdisciplinary staff internal and external to the organization.
Participates in quality improvement and evaluation processes related to the management of care.
Managing daily work activities, ensuring quality, productivity and efficiency while assisting in accomplishing strategic and operational objectives.
Conduct thorough initial and discharge psychosocial assessments to identify patient needs and barriers.
Document social work interventions in the medical chart consistently, aligning with the discharge plan of care.
Ensure compliance with State and Federal regulatory requirements, including CMS Conditions of Participation for discharge planning.
Collaborate effectively with interdisciplinary team members to coordinate inpatient discharge planning.
Assist patients and families in navigating post-acute care options, including home health agencies, skilled nursing facilities, and rehabilitation services.
Facilitate crisis intervention when necessary, providing immediate support for patients in distress.
Organize case conferences for patients and families to discuss ongoing needs and resources available.
Provide emotional support and resource information to patients and their families throughout their hospital stay.
Maintain effective communication between patients, families, and healthcare teams to ensure continuity of care.
Offer social work coverage during evenings, weekends, and holidays as assigned by management.
Take on additional duties as needed that relate to the position.