Social Work Care Manager

Emory•Atlanta, GA

About The Position

The Social Work Care Manager I (SW CM I) coordinates patient care from admission through discharge to support smooth transitions, high-quality clinical and cost outcomes, timely access to post-acute services, and efficient care delivery. The role completes admission and/or psychosocial assessments, begins discharge planning, and identifies and addresses barriers to care coordination. As an integral member of the interdisciplinary care team, the SW CM attends rounds, care conferences, and care team meetings and works with patients, families, hospital staff, and external stakeholders to develop and implement appropriate plans that account for clinical needs, available services, and patient and family preferences. The SW CM identifies appropriate post-acute services, makes referrals, and continually reassesses whether services remain appropriate as the patient’s clinical status changes. The role aligns discharge plans with the medically cleared discharge date and the payer’s projected length of stay, and helps develop strategies to reduce unnecessary length of stay and resource use. Cases may be escalated to management, the Physician Advisor, the Complex Care team, and/or the Ethics committee. The SW CM educates patients, families, and care teams about post-acute services, transitions of care, readmission mitigation, levels of care, and available resources; provides supportive and therapeutic communication; and 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, non-authorized, 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 applicable payer and government and state regulatory requirements and uses case management systems and workflows appropriately. The position has physical demands including lifting and carrying up to 25 pounds, occasional to frequent standing and walking, occasional sitting, and close eye work such as computer use, typing, reading, and writing. Environmental exposures may include blood-borne pathogens, biohazardous waste, chemicals, communicable diseases, electrical shock, varied floor surfaces and temperatures, indoor and outdoor conditions, latex, patient-care handling injuries, and radiation. Personal protective equipment, including respirators, may be required. Conditions vary by work area and tasks; travel may be required.

Requirements

Master’s degree in Social Work from an accredited institution.
Working knowledge of software and electronic medical record (EMR) applications.
Must meet quality and productivity expectations and successfully complete yearly competencies.
Ability to lift and carry up to 25 pounds.
Ability to perform close eye work, including computer use, typing, reading, and writing.
Ability to use personal protective equipment, including respirators, when required.

Nice To Haves

One year of recent healthcare experience preferred.
Acute care setting experience preferred.
ACM or CCM credential preferred.

Responsibilities

Coordinate patient care from admission through discharge and facilitate transitions of care.
Complete admission and/or psychosocial assessments and begin discharge planning promptly.
Identify and address barriers to care coordination and discharge planning.
Participate in interdisciplinary rounds, care conferences, and care team meetings.
Work with patients, families, the hospital care team, and external stakeholders to develop and implement appropriate care plans.
Identify post-acute services and make timely referrals to appropriate providers.
Continuously reassess post-acute service needs as the patient’s clinical condition progresses.
Align discharge plans with the medically cleared discharge date and the payer’s 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, levels of care, and available resources.
Provide supportive and therapeutic communication to patients and families experiencing stress related to illness, injury, or physical limitations.
Respond to suspected violence, assault, abuse, and/or neglect in accordance with social work professional ethics.
Collaborate with Utilization Review to facilitate payer discussions and advocate regarding non-covered, non-authorized, or denied services.
Serve as a resource on external regulations and organizational policies and procedures concerning discharge planning and care coordination.
Ensure compliance with payer and applicable federal and state regulatory requirements.
Use case management systems and workflows appropriately.
Meet quality and productivity expectations and successfully complete yearly competencies.