Case Manager, Discharge (BSW or MSW)

Mary Washington Healthcare•Fredericksburg, WA

About The Position

The Case Manager, Discharge organizes and expedites care plans for patients with medically complex needs and difficult social issues related to hospital progression. The role identifies discharge needs and develops discharge plans, coordinates care with clinical partners, promotes communication among care providers, and provides patients and families with information and education about community resources. The position also addresses child and elder abuse or neglect, guardianship issues, end-of-life treatment decisions, and Medical Power of Attorney matters. The social worker provides advanced support in difficult conversations, needs assessments, public assistance resources, crisis intervention, and trauma-informed care. The role serves as a subject matter expert and resource for care team members, mentors new social work Associates and student interns, helps coordinate post-discharge needs, and participates in quality improvement activities.

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.
Critical-thinking and analytical skills.
Ability to multitask, communicate effectively, and collaborate with a multidisciplinary team.
Ability to cope with difficult situations.
Ability to tolerate irregular hours, including evenings, nights, and weekends.
Ability to meet the stated physical requirements, including lifting 35 pounds and pushing or pulling up to 20 pounds.
Ability to wear appropriate personal protective equipment.

Nice To Haves

Experience in a healthcare field.
Case Management Certification is strongly desired.

Responsibilities

Coordinate patient care with clinical partners and help patients progress toward realistic, desirable outcomes.
Serve as a subject matter expert and resource for care team members.
Mentor new social work Associates in Care Coordination 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 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 for medically complex needs and difficult social issues.
Document assessments and overall discharge plans in the medical record.
Assist with audits and assessments of discharge-planning documentation and help with complex care coordination situations.
Partner with leadership to address discharge delays, barriers, and identified trends.
Serve as a point of contact and resource for immediate post-discharge patient needs.
Intervene in cases involving child or elder abuse or neglect and guardianship.
Provide guidance regarding end-of-life treatment decisions and Medical Power of Attorney.
Facilitate meetings and comprehensive care planning with the interdisciplinary team.
Delegate work to support team members.
Use post-acute care facilities in safe and effective discharge planning.
Collaborate with contracted financial partners to facilitate post-acute facility placement.
Conduct psychosocial assessments as needed to develop appropriate discharge plans for medically complex needs and difficult social issues.
Participate in planning and implementing quality improvement activities.
Perform other duties as assigned.