Clinical Social Worker Case Management FT Days
About The Position
The Social Worker facilitates care across the continuum through effective resource coordination, helping patients achieve optimal health, access care, and use resources appropriately while respecting their resources and right to self-determination. The role assesses transition needs, including identifying patients at risk for readmission, and conducts complex psychosocial assessments and interventions to support timely throughput, safe discharge, and prevention of avoidable readmissions. The position integrates national case management standards in transition management, care coordination, regulatory compliance, and education. Responsibilities include psychosocial transition planning and reassessment; assistance with adoption, abuse, and neglect cases; care coordination and implementation of transition plans; facilitating multidisciplinary patient care conferences; referrals; communication with patients and families; collaboration with physicians and hospital teams; patient education; and timely, accurate documentation and maintenance of patient demographic and insurance information.
Requirements
- Master's degree in Social Work from a program approved by the Michigan Board of Social Work and accredited by the Council on Social Work Education.
- Current Michigan Licensed Master's Social Worker license, or a current limited license to practice social work at the master's level in Michigan; full licensure is required within three years from the date of hire.
- Analytical ability, critical thinking, and problem-solving skills.
- Interpersonal skills to work productively with patients, families, and hospital personnel at all levels.
- Verbal and written communication skills to communicate effectively with diverse populations, including physicians, employees, patients, and families.
- Ability to manage stressful situations, multiple and conflicting priorities, and difficult medical, emotional, and psychosocial problems.
- Teaching ability to conduct educational programs for staff, patients, families, and the community.
- Organizational skills and ability to lead and coordinate diverse groups in a fast-paced environment.
- Knowledge and physical ability to systematically assess patients and families to identify psychosocial health status and needs.
- Computer literacy to use case management systems.
- Attendance at hospital and department orientation is required.
Nice To Haves
- Two years of acute hospital experience preferred.
- Accredited Case Manager (ACM) certification preferred.
Responsibilities
- Complete a comprehensive assessment within 24 hours of admission to identify and document the anticipated transition plan.
- Integrate patient assessment, patient choice, and available resources to develop and implement a successful transition plan.
- Complete complex psychosocial assessments and plans for patients at high risk for readmission.
- Provide psychosocial assessment and intervention for patients with needs involving behavioral health, limited support systems, financial barriers, end-of-life concerns, or medication adherence.
- Delegate implementation of transition plans when appropriate and follow up to ensure timely and accurate completion.
- Ensure transition-plan elements are implemented and communicated to the healthcare team, patient and family, and post-acute providers.
- Provide patients with information to support informed choices about community services under Tenet policy.
- Complete the Final Discharge Disposition Form Assessment for Medicare patients under Tenet policy.
- Document completely, accurately, and promptly in the Tenet Case Management system and provide documents needed in the patient record.
- Screen patients for factors affecting progression of care and intervene to promote timely and appropriate throughput.
- Assess and stratify patients at risk for readmission or in need of case management services.
- Assist with adoption, abuse, and neglect cases and report appropriate cases to local, state, or federal agencies.
- Ensure the plan of care is consistent with patient choice and available resources, and that patient needs are communicated to the healthcare team.
- Collaborate with physicians, nurses, ancillary staff, payors, patients, and families to achieve optimal outcomes.
- Provide or ensure education for patients, physicians, and the healthcare team concerning safe and timely transitions, available resources and benefits, and the economic impact of care options.
- Ensure patients, families, or caregivers receive education from the healthcare team before discharge.
- Comply with applicable federal, state, and local regulations, accreditation requirements, CMS Conditions of Participation, Tenet policies, and department policies and procedures.
- Practice within the Social Work scope of practice defined by state licensing regulations.
- Attend hospital and department orientation, including instruction on Tenet Case Management and Compliance policies and transition management.
- Complete and demonstrate competency in the Tenet Case Management documentation system within 30 days of hire.
- Perform other duties as assigned.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
