Lead Social Worker / RN Case Manager (DH2110)

Tuba City Regional Health Care • Tuba City, AZ

123d

About The Position

Incumbent serves as Lead Social Worker/Registered Nurse (RN) Case Manager for TCRHCC and Sacred Peaks Healthcare Center (SPHC) and is responsible for direct supervision and supportive contact for the specific group of identified high-risk patients. The Lead Social Worker/RN Case Manager is responsible for assisting the Director of Care Coordination, with management of the MSW and Case Managers with onboarding program, the day to day assignments, assisting in routine reporting, and supervisory duties. To the designing and managing a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency. The Lead Social Worker/RN Case Manager is responsible for assessment, service planning, and resource acquisition, monitoring progress and initiating and responding to emerging client needs. The Lead Social Worker/RN Case Manager will link the client with Community Social Service providers, health care providers, substance abuse, and mental health providers to achieve specific goals. The Lead Social Worker/RN Case Manager will have experience working with culturally diverse low-income populations having multiple barriers to self-sufficiency such as: illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. The Lead Social Worker/RN Case Manager will work with a multidisciplinary team within the service delivery setting. The Lead Social Worker/RN Case Manager will be committed to Case Management Services and have some assignments with Purchased and Referred Care (PRC) formally known as Contract Health Services, providing assistance to the PRC Case Specialist. The Lead Social Worker/RN Case Manager will be responsible to the Director of Case Care Coordination.

Requirements

• Master's Degree in Social Work (MSW) for MSW Social Worker
• Associates degree in Nursing for RN Case Manager
• Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association throughout employment
• Licensed Master Social Worker (LMSW) for MSW Social Worker
• A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
• Minimum of three (3) years of experience in the clinical care setting or with case management
• Demonstrate knowledge of electronic health record systems
• A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers
• Effective verbal & written communication skills
• Team management focus promoting a positive and pro-active approach to problem resolution
• Successful completion of and positive results from all background and reference checks
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information

Responsibilities

• Responsible for assisting the Director of Care Coordination, managing the MSW and Case Managers with onboarding program, the day to day assignments, assisting in routine reporting, and supervision of staff
• Coordination of service specific assessments, service planning and enrollment
• Works with all facets of the Case Management continuum, i.e., social support, alternate resources, community referrals, discharge planning, Nursing Home/Skilled Nursing Placement and resource utilization
• Comprehensive and client centered service planning and coordination
• Work proactively with the established RN Case Managers/ Social Workers of TCRHCC as a team member for care coordination of the patient populations served by TCRHCC
• Resource acquisition, facilitate referrals and connect clients to those resources and referrals
• Consistent and on-going case consultation with all direct service providers
• Develop and maintain internal and external resource relationship
• Responsible for service monitoring and following up to ensure continuity of care and updating of the client service plan
• Identify patient through consultation and high-risk diagnoses, i.e. COPD, CHF, DM
• Assist with the development of department reports, policy/procedures manuals, and program objectives
• Assist with special projects as assigned
• Conduct system and procedural efficiency evaluation to determine progress, performance, and conformity with program requirements
• Assist in managing outpatient referrals for PRC
• Follow up outside inpatient referrals for continued follow up, I.E., appointments and PHN referrals
• Provide coverage for the inpatient units-ACU, PEDS, ICU, OB, and ER to include Outpatient Clinics
• Manages care of prioritized TCRHCC/SPHC outpatient/inpatient based upon consultation from providers within the TCRHCC/SPHC healthcare delivery system; provides a consistent and on-going consultation with service providers
• Work proactively and collaboratively with Utilization Review (UR), Public Health Nursing (PHN), Patient Benefit Coordinators (PBC), and Purchased Referred Care (PRC) at TCRHCC/SPHC
• Facilitate communication and coordination between members of the health care team, involving the client in the decision-making process in order to minimize fragmentation in the services
• Develop with the patient/family and multidisciplinary team (including service area and/or other non-TCRHCC/SPHC providers as appropriate) a care and service delivery plan based upon the needs identified and available provider and financial resources of the patient and provides consistent and on-going case consultation with all direct service providers
• Provide service monitors and follow up to ensure continuity of care, and updates of the client service plan and provides follow up if needed
• Strive to promote client self-advocacy and self-determination
• Prepare patient and family for termination (discharge) from case management when services are no longer required
• Arrange for any ongoing support/direct care services that the patient will need post-discharge in coordination with discharge planners and other entities such as PHN, Community Health Representatives or Tribal Social Services
• Will be familiar with Advance Directives and be a resource person for patients and families; facilitate informed choice, consent, and decision-making
• Promote use of evidence-based care, as available, in conjunction with the MCG Care Guidelines
• Pursue professional excellence and maintain competence in practice
• Serve as the outpatient/inpatient coordinator with duties to include primary contact for outpatient/inpatient in obtaining beds for admissions both within and outside of TCRHCC/SPHC
• Collaborate with provider and nursing personnel to ensure admissions are conducted seamlessly and without delay of patient care
• Collaborate with provider, nursing personnel and patient benefits coordinators that all admission documentation is complete and all referrals for third party resources are complete prior to the departure of patients
• Provide coverage in all units, inpatient and outpatient for staffing shortages, as necessary
• Incumbent will be required to take call on scheduled weekends, as necessary
• Ensure proper PPE is worn at all times while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield
• Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly
• Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction
• Performs other duties as assigned

What This Job Offers

• Job Type: Full-time
• Education Level: Master's degree
• Number of Employees: 1,001-5,000 employees