Social Work Care Manager

McLaren Health Care•Petoskey, MI

About The Position

The Social Work Care Manager provides assessment and intervention to help clients and families address social and economic difficulties that affect health and wellness, using casework principles, strategies, and community resources. The role provides professional discharge planning through assessment and coordination of post-hospital care needs, helping patients and families access resources and make choices that support emotional, medical, and spiritual care. The position also receives referrals for people from at-risk populations from interdisciplinary team members.

Requirements

Licensed Master’s Social Worker (LMSW); obtain LMSW certification within one year of eligibility and maintain continuing education requirements.
American Case Management Certification (ACM), or obtain certification when eligible as defined by the Association Case Management Association, and maintain continuing education requirements.
Ability to handle crisis situations and act calmly and effectively in a busy, stressful environment.
Ability to manage multiple tasks, organize and prioritize work, and complete it within short timeframes.
Ability to manage patients with different types of personalities.
Ability to spend most of the work time using a computer, monitor, keyboard, and mouse, and ability to type.
Ability to solve practical problems and work with concrete variables in situations with limited standardization.
Ability to work with diverse teams and individuals as a team player.
Competency in applying the principles, methods, materials, and equipment necessary to provide case management services.
Comply with the Code of Ethics and Guide for Professional Conduct.
Maintain current knowledge of treatment theories, practices, and techniques for the discipline.
Customer-focused attitude and ability to work proactively and efficiently with appropriate urgency.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and policy and procedure manuals.
Demonstrated leadership through professionalism, teamwork, observation, communication, and decision-making abilities.
Knowledge of computerized hospital and health information management systems and software, such as Cerner, Paragon, Meditech, InterQual, and Optum, and Microsoft Office applications.
Strong interpersonal skills to communicate effectively with physicians, nursing staff, patients and families, utilization management, and internal and external customers.
Maintain knowledge of applicable CMS rules and billing regulations related to Medicare, Medicaid, and commercial insurance.
Ability to work independently and use problem-solving techniques and critical-thinking skills.
Weekend, holiday, and evening coverage as required by site.

Nice To Haves

Certification in case management (ACM or CCM).
Three years of acute hospital care or social work experience.
Basic Life Support (BLS) certification as a Healthcare Provider from the American Heart Association, American Red Cross, or equivalent through the Military Training Network (MTN).

Responsibilities

Triage patients, prioritizing those with complex psychosocial or financial issues, placement needs, and community service needs within 24 hours of admission.
Receive referrals from RN Care Managers based on identified Social Work Triggers.
Identify and assess barriers early in the patient’s stay and develop plans with the patient, family, healthcare team, payers, and community resources.
Assess patient and family support and community service needs; provide education and referrals, help arrange access to services and appointments, and build relationships with other agencies.
Assess readmission risk for specified patient populations and initiate assigned interventions to support successful transitions across the care continuum.
Identify the need for, arrange, and participate in family care conferences; participate in interdisciplinary conferences and provide consultation to patients, families, and clinical staff.
Identify and report avoidable days, variances, and service delays from the established plan of care to leadership.
Identify patient and family preferences, needs, and strengths for the interdisciplinary team in accordance with standards of care.
Interview patients and significant others to assess psychosocial circumstances and identify the family member who will serve as the point of contact.
Develop discharge plans in consultation with the patient, family, physician, and healthcare team.
Manage complex cases and situations, intervening and advocating for patients and families as plans of care and discharge plans are developed.
Apply knowledge of insurance benefits and coverage guidelines to maximize appropriate use of resources.
Document assessments, plans, interventions, barriers, and reassessments in the EMR to facilitate discharge and transitions; ensure relevant information is transferred to post-acute agencies.
Collaborate with RN Care Managers and other internal and external healthcare team members to support safe, appropriate, and timely transitions to the next level of care, considering the patient’s available resources.
Partner with external agencies and facilities to support continuity of care and patient and family empowerment and independence in health decisions.
Represent the integrated care management department on teams, performance-outcomes committees, and projects.
Perform other related duties as required and directed.