Inpatient Registered Nurse or Social Worker (MSW) Care Manager, Part-Time, Upper Bucks Campus

St Luke's University Health Network • Quakertown, PA

77d

About The Position

The Social Worker Care Manager is responsible for coordinating the complex discharge planning needs of patients, as well as to provide supportive counseling, psycho-social assessment and interventions for designated patient populations across the continuum of care. Also works with the providers, registered nurse care managers, and multi-disciplinary care teams to facilitate the achievement of desired patient, quality, and financial outcomes.

Requirements

• MSW or equivalent from an accredited school of social work.
• Current NJ SW license if working at St. Luke's Warren Campus.
• Preference for at least two years of experience as a Social Worker in an acute hospital setting.
• Strong critical thinking skills.
• Ability to maintain collaborative and effective working relationships.
• Knowledge of medical terminology required.
• Ability to communicate both verbally and in written forms.
• Basic computer skills required.

Nice To Haves

• Membership in the National Organization of Perinatal Social Workers if primary coverage area is OB.

Responsibilities

• Develops a discharge plan that addresses the psycho-social needs to meet desired goals for the next step in the continuum of care for patients.
• Collaborates with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient's needs and goals.
• Works as a team with other members of care management, including but not limited to: RN care managers, assistants, coordinators, utilization management staff, and director.
• Facilitates communication among all treatment team members.
• Manages length of stay by proactively identifying and mitigating issues and barriers to care and a successful discharge plan.
• Updates the care team, patient/family as to the status of the discharge plans. Re-evaluates and revises the discharge plan as additional information is acquired.
• Proactively considers options such as palliative care, homecare and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of readmissions.
• Issues applicable state/federal regulatory notices as applicable ie.) Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle Payment Care Initiative (BPCI) notification.
• Monitors risk assessment using available tools and implements discharge interventions accordingly.
• Actively addresses and monitors resource utilization and documents delays as appropriate.
• Identifies patients with an unplanned readmission and completes root cause analysis.
• Coordinates utilization of patient and community resources to facilitate achievement of a safe and effective discharge plan and accomplishment of goals as well as minimizing risk of readmission.
• Collaborates with Outpatient Care Managers to identify patients for handover and post discharge follow up.
• Provides supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement. Facilitates the decision making process in complex cases.
• Facilitates resolution of issues surrounding patient care in a compassionate manner, utilizing team meetings as appropriate.
• Act as resource to the staff for regulatory issues regarding discharge-planning and psychosocial processes.
• Uses electronic systems to accurately document care manager functions.

What This Job Offers

• Career Level: Entry Level
• Industry: Hospitals
• Education Level: Master's degree
• Number of Employees: 5,001-10,000 employees