Social Services Care Manager

Northwestern Medical Center•St. Albans, VT

5d•Onsite

About The Position

Northwestern Medical Center (NMC) is seeking a per-diem Social Services Care Manager to join their Case Management team. This role primarily involves working from 8:00 a.m. to 4:30 p.m., with an expectation of working one weekend per month. NMC is committed to providing exceptional healthcare and values its employees, prioritizing their health and well-being. The position offers a hiring range of $35.45-$49.52, plus per-diem rates and applicable shift differentials. Compensation will be determined based on relevant experience, internal equity, qualifications, and alignment with role requirements. The Social Services Care Manager will conduct individualized clinical evaluations of patients, assess their health needs, review medical records for necessity, develop personalized action plans, provide education, and make referrals for post-acute care. They will monitor patient progress, modify care plans, and provide clinical information to health insurers. This role involves working closely with an interdisciplinary care team to identify and manage high-risk patients, coordinate care planning, manage referrals, plan for post-discharge, and facilitate transitional care within the community. Building strong, team-oriented relationships with physicians, nurses, and other healthcare professionals is key, as is evaluating and reporting on patient health outcomes. The manager will direct the discharge planning process, assist with transitions from inpatient to post-discharge care, involve patients and caregivers in planning, and advocate for appropriate hospital stays. They will also guide, intervene, and advocate for patients and families navigating the healthcare system and coordinate community resources. Accurate and timely record-keeping is essential, and the role requires working independently in a fast-paced environment.

Requirements

Master's Degree in Social Work, Counseling or Psychology.
LMSW strongly preferred.
Three years in a hospital &/or clinic setting preferred.
Case management experience preferred.
Community care management experience preferred.
Certified Case Manager preferred.
Exceptional communication skills in a wide variety of settings.
Ability to work professionally & effectively with physicians, other healthcare providers, & community members.
Willingness to be flexible to meet patient/family/organization needs.
BLS required.

Nice To Haves

LMSW
Certified Case Manager

Responsibilities

Conduct individualized concurrent clinical evaluations of patients, their health needs, and concerns.
Review patient medical record for medical necessity, develop personalized action plans, provide education, and issue referrals for post-acute care.
Monitor patients’ progress in meeting established goals and modify care plans accordingly.
Provide clinical information to health insurers as required.
Work closely with interdisciplinary care team and technology to identify high-risk, complex patient cases.
Manage care, provide care planning, referral management, post-discharge planning, and coordinating community-based and transitional care.
Develop a cohesive and strong team-oriented relationship with physicians, nurses, and other healthcare professionals.
Evaluate and report on patient health outcomes and work in partnership with interdisciplinary healthcare team to facilitate the best in patient care.
Direct discharge planning process in support of treatment adherence and medication compliance.
Assist with transitions for patients discharged from an in-patient hospital to post-discharge care.
Include patients and caregivers in transition of care planning.
Advocate for decreased hospital stay when appropriate.
Guide, intervene and advocate on behalf of patients, their caregivers and/or families regarding navigating and comprehending the healthcare system.
Coordinate resources in the community to ease transition.
Maintain accurate and timely records of all patient-related interactions.
Collaborates with internal staff and outside agencies to meet the needs of the patient and their families.
Collaborates with SRS/DCF/APS for issues regarding children and vulnerable adults and files appropriate reports as required by law.
Assists patients of all ages to provide information on resources/services available.
Utilizes community service providers to maximize the patient's ability to function in the community.
Makes appropriate referrals to social service agencies related to financial concerns for adult patients.
Coordinates support for post partum mothers and their infants.
Provides information to patients and families regarding end of life care and options.
Supports the emotional needs of patient/family when discussing and/or planning placement in a skilled nursing facility or other long-term care solution respecting feelings regarding their loss of independence.
Supports emotional and clinical needs of chronic disease management, as well as diagnosis.
Assists patients with identifying support systems and services post discharge.
Coordinates with & contributes to inpatient discharge planning activities to ensure patients’ needs are being met, roadblocks/barriers to discharge are addressed, appropriate services/supports are offered.
Communicates with long-term care facilities and home health agencies to facilitate transition back to community setting.
Provides information to patient and family that is age specific and appropriate for their level of understanding.
Acts as a liaison between provider and patient/family to answer questions, clarify issues, and gather information.
Provides information to patients/family to improve their understanding of medical recommendations.
Conducts patient record review to determine appropriateness of admission based on established criteria.
Communicates with providers to ensure appropriate level of care, efficient use of resources, payor requirements, and plans for discharge.
Collects data related to LOS, denied days, resource consumption and patterns and explores strategies to manage utilization and decrease variation.
Updates insurance providers as needed regarding plan of care.