Case Manager, Discharge (BSW or MSW)
About The Position
The Case Manager, Discharge organizes and expedites treatment plans for patients with medically complex needs and difficult social issues related to hospital progression of care. The position identifies discharge needs, develops discharge plans, promotes communication and collaboration among care providers, and educates patients and families about community resources. The Case Manager coordinates care with clinical partners and provides support regarding child or elder abuse and neglect, guardianship, end-of-life treatment decisions, and Medical Power of Attorney. The Social Worker has advanced training and additional fieldwork in difficult conversations, client needs assessments, public assistance resources, crisis intervention, and trauma-informed care, and is eligible for the LMSW examination. The role also mentors new social work Associates and student interns, supports discharge planning quality improvement, and serves as a resource for care teams and immediate post-discharge needs.
Requirements
- Master’s degree in Social Work.
- At least one year of social work experience, or completion of a two-semester internship within the MWHC Care Coordination department.
- Experience with computer technology, including Windows-based programs, email, and Microsoft Word.
- Ability to use critical thinking and analytical skills, multitask, communicate effectively, and collaborate with a multidisciplinary team.
- Ability to cope with difficult situations and tolerate irregular hours, including evenings, nights, and weekends.
- Physical ability to use arms and hands constantly; stand, walk, and sit frequently; bend, stoop, and squat occasionally; lift 35 pounds; and push or pull up to 20 pounds.
- Auditory and visual skills, including color determination.
- Ability to wear appropriate personal protective equipment when needed due to potential exposure to bloodborne pathogens.
Nice To Haves
- Experience in a healthcare field preferred.
- Case Management Certification strongly desired.
Responsibilities
- Coordinate patient care with clinical partners and help patients progress toward realistic and desirable outcomes.
- Serve as a subject matter expert and resource for care team members.
- Mentor new social work Associates in the Care Coordination department and social work student interns.
- Assess long-term and future patient care needs, including probable changes in independence or functional quality.
- Communicate treatment plan activity status updates to clinical partners.
- Provide patients and families with information and education about community resources.
- Develop, coordinate, and communicate discharge plans with patients, families, and the care team; document assessments and plans in the medical record.
- Assist with audits and assessments of discharge planning documentation and complex care coordination situations.
- Partner with leadership to address discharge delays, barriers, and observed trends.
- Serve as a point of contact and resource for immediate post-discharge patient needs.
- Provide intervention in cases involving child or elder abuse or neglect and guardianship.
- Provide guidance on treatment decisions involving end of life and Medical Power of Attorney.
- Facilitate interdisciplinary meetings and comprehensive care planning, and delegate work to support team members.
- Use post-acute care facilities in safe and effective discharge planning.
- Collaborate with contracted partners regarding financial needs to facilitate post-acute facility placement.
- Conduct psychosocial assessments as needed to develop appropriate discharge plans for medically complex cases and difficult social issues.
- Participate in planning and implementing quality improvement activities.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
