Social Work Care Manager

Emory•Atlanta, GA

About The Position

The Social Work Case Manager II (SW CM) coordinates patient care from admission through discharge to support smooth transitions from the hospital, high-quality clinical and cost outcomes, timely procurement of post-acute services, and effective coordination with patients, families, and internal and external stakeholders. The role identifies and addresses barriers to care coordination and discharge planning to support efficient care delivery and maximize reimbursement. The SW CM begins care coordination at admission by completing an admission and/or psychosocial assessment and developing a discharge plan. As an integral member of the interdisciplinary care team, the SW CM attends rounds, care conferences, and care team meetings; collaborates with patients, families, and clinicians to plan and implement appropriate care; and makes timely referrals to post-acute providers. The case manager continuously assesses whether post-acute services remain appropriate as the patient’s clinical condition changes, and works to align the discharge plan with medical clearance and the payor’s projected length of stay. The position supports strategies to reduce unnecessary length of stay and resource use, escalating cases when appropriate to management, the Physician Advisor, the Complex Care team, or the Ethics committee. The SW CM educates patients, families, and care team members about post-acute services, care transitions, readmission mitigation, levels of care, and available resources, and provides supportive, therapeutic communication to people experiencing stress related to illness or injury. The role responds to suspected violence, assault, abuse, or neglect in accordance with social work professional ethics. In collaboration with Utilization Review, the SW CM facilitates discussions with payors and advocates for patients and the hospital regarding non-covered, unauthorized, or denied services. The role advises physicians, the interdisciplinary care team, and patients on external regulations and organizational policies related to discharge planning and care coordination; ensures compliance with payor and regulatory requirements; and uses case management systems and workflows appropriately.

Requirements

Master’s degree in Social Work from an accredited institution.
LMSW license in the state of Georgia.
Working knowledge of software and electronic medical record applications.
Must meet quality and productivity expectations and successfully complete yearly competencies.
Physical ability to lift and carry up to 25 pounds; work may involve standing, walking, sitting, and close eye work such as computer use, typing, reading, and writing.

Nice To Haves

Two years 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 and begin discharge planning promptly.
Participate in interdisciplinary rounds, care conferences, and care team meetings.
Collaborate with patients, families, and the care team to develop and implement appropriate care and discharge plans, accounting for preferences and service availability.
Identify appropriate post-acute services and make timely referrals to providers; reassess their appropriateness as the patient’s clinical status changes.
Align discharge plans with the medically cleared discharge date and the payor’s projected length of stay.
Identify and participate in strategies to reduce unnecessary length of stay and resource consumption.
Escalate cases when appropriate to management, the Physician Advisor, Complex Care team, and/or Ethics committee.
Educate patients, families, and care team members about post-acute services, transitions of care, readmission mitigation, levels of care, and available resources.
Provide supportive and therapeutic communication to patients and families experiencing anxiety or stress due 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 discuss coverage and authorization issues with payors 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 payors and federal and state regulatory agencies.
Use case management systems and workflows properly.
Meet quality and productivity expectations and successfully complete yearly competencies.