Social Work Care Manager

Emory Healthcare•Atlanta, GA

6d•$34 - $40

About The Position

The Social Work Care Manager I (SW CM I) coordinates patient care from admission through discharge, supporting smooth transitions from the hospital and high-quality clinical and cost outcomes. The role secures post-acute services, coordinates and advocates for patients and families with internal and external stakeholders, and identifies barriers to care coordination and discharge planning to support efficient care delivery and maximize reimbursement. Beginning at admission, the SW CM completes an admission and/or psychosocial assessment to capture information accurately and promptly and begin discharge planning. As an integral member of the interdisciplinary care team, the SW CM participates in rounds, care conferences, and care team meetings. The role represents both the hospital care team and the patient and family, balancing their preferences with the services that can be arranged. The SW CM identifies appropriate post-acute services, makes timely referrals, and continually reviews whether those services remain appropriate as the patient’s clinical status changes. The discharge plan should align with the medically cleared discharge date and the projected length of stay provided by the payer. The SW CM works to reduce unnecessary length of stay and resource use, escalating cases when appropriate to management, the Physician Advisor, Complex Care team, or Ethics committee. The role educates patients, families, and care teams about post-acute services, transitions of care, readmission mitigation, care-level choices, and available resources. It also provides supportive and therapeutic communication to people experiencing stress related to illness, injury, or physical limitations, and responds to suspected violence, assault, abuse, or neglect in accordance with social work professional ethics. In collaboration with Utilization Review, the SW CM initiates and facilitates discussions with payers, advocating for the patient and hospital to reduce non-covered, unauthorized, or denied services. The role advises physicians, the interdisciplinary care team, and patients on external regulations and organizational policies and procedures relating to discharge planning and care coordination. The SW CM ensures compliance with government and commercial payer requirements and federal and state regulations, and uses case management systems and workflows appropriately.

Requirements

Master’s degree in Social Work from an accredited institution.
Working knowledge of software and electronic medical record (EEMR) applications.
Must meet quality and productivity expectations and successfully complete yearly competencies.
Ability to meet the stated physical demands, including lifting and carrying up to 25 pounds.

Nice To Haves

One year of recent healthcare experience preferred.
Experience in an acute care setting preferred.
ACM or CCM certification preferred.

Responsibilities

Coordinate patient care from admission through discharge and facilitate transitions from the hospital.
Complete admission and/or psychosocial assessments to support timely information capture and discharge planning.
Participate in rounds, care conferences, and care team meetings as an interdisciplinary care team member.
Coordinate and advocate for patients and families with internal and external stakeholders while balancing preferences with feasible care plans.
Identify post-acute services and submit timely referrals to appropriate providers in coordination with patients, families, and the care team.
Continuously assess whether post-acute services remain appropriate as the patient’s clinical condition progresses.
Align the discharge plan with the medically cleared discharge date and payer-provided projected length of stay.
Identify and participate in strategies to reduce unnecessary length of stay and resource consumption.
Escalate cases as appropriate to management, the Physician Advisor, the Complex Care team, and/or the Ethics committee.
Educate patients, families, and care teams about post-acute services, transitions of care, readmission mitigation, appropriate levels of post-acute care, and available resources.
Provide supportive and therapeutic communication to patients, families, and loved ones experiencing anxiety or stress related to illness, injury, or physical limitations.
Respond to suspected violent, assault, abuse, and/or neglect cases in accordance with social work professional ethics.
Collaborate with Utilization Review to initiate and facilitate payer discussions and advocate regarding non-covered, unauthorized, or denied services.
Serve as a resource on external regulations and organizational policies and procedures related to discharge planning and care coordination.
Ensure compliance with government and commercial payer requirements and federal and state regulatory agencies.
Use case management systems and workflows properly.
Meet quality and productivity expectations and successfully complete yearly competencies.