Medical Social Work - Care Management
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About The Position
PeaceHealth is seeking a Care Management/Medical Social Worker for a Full Time, 0.90 FTE, Day position. This role is crucial for identifying and interacting with medically and psychosocially complex patients and families who are likely to benefit from care management and meet high-risk criteria. The primary responsibility includes coordinating discharge planning services for these patients in collaboration with RN Care Management and other members of the care team. The Medical Social Worker will screen and identify patients who need care management based on high-risk criteria. They will assess, develop, implement, and monitor a comprehensive discharge plan of care through an interdisciplinary team process in conjunction with the patient and family. This involves collaborating with the multi-disciplinary team to identify problems or needs that require special planning, intervention, teaching, or follow-up. The role also requires identifying key problems, strengths, and resources to be addressed in the discharge plan of care, and coordinating and facilitating improved ability to comply with the treatment plan. Additionally, the Medical Social Worker will actively support measures that promote effective use of resources, plan and arrange for appropriate services using knowledge of available community, state, and federal health regulations, and coordinate effective planning and arranging for needed services upon discharge. They will provide psychosocial support to prepare the patient and their family to manage their healthcare needs within the acute care setting and post-discharge. The position also involves conducting evaluations, documenting the effectiveness of Care Management services, and collaborating with team members to adjust plans if the patient's health status is not improving. The Medical Social Worker may also counsel patients and/or families to facilitate participation in community care services, assess and address mental health and chemical dependency conditions, and perform risk assessments for suicidality and homicidality. Other duties may be assigned as necessary.
