Social Worker - Care Manager - Mary Immaculate Hospital

Bon Secours Mercy Health•Newport News, VA

About The Position

The Social Worker Care Manager at Mary Immaculate Hospital provides interventions and discharge planning for patients and families, facilitating transitions throughout the continuum of care by accessing hospital, community, and governmental resources. The role also provides clinical supervision to peers, social workers, and students. The position identifies patients’ social-service needs using a holistic biopsychosocial, functional, cultural, spiritual, and financial approach. It works with patients, caregivers, and the healthcare team to support quality, cost-effective outcomes; monitors and revises plans as patient conditions change; and maintains timely, clear documentation of care plans, post-hospital needs, resources, and patient or caregiver involvement. The role incorporates patient and caregiver goals and preferences into transition planning and communicates them to the multidisciplinary team. The Social Worker Care Manager follows standardized practices for advance care planning, length-of-stay management, and readmission prevention. It supports denial prevention by addressing barriers to care progression and participating in interdisciplinary discharge rounds, promotes timely testing and treatment, and helps the care team use resources appropriately, including considering alternatives to acute care.

Requirements

Bachelor of Social Work.
BLS Basic Life Support certification from the American Heart Association.
Social Worker license in the state of practice.
At least 1 year of experience in a clinical setting.
Ability to prioritize simultaneous demands and tolerate frequent interruptions.
Skills in social work care management, ethics, end-of-life ethics, patient advocacy, clinical supervision, and Microsoft Office.
Interpersonal skills including attention to detail, critical thinking, communication, conflict resolution, active listening, relationship building, problem solving, teamwork, collaboration, empathy, negotiation, time management, and prioritization.

Nice To Haves

Master’s degree in social work or a healthcare-related field.
Social Worker licensure in Virginia.
Accredited Case Manager (ACM) certification from the American Case Management Association or Certified Case Manager (CCM) certification from the Commission for Case Manager Certification.
At least 3 years of experience in an acute-care clinical setting.
Ambulatory or post-acute care coordination experience.

Responsibilities

Identify and prioritize patients needing social services using a holistic assessment of biopsychosocial, functional, cultural, spiritual, and financial factors.
Plan with patients, caregivers, and healthcare team members to maximize care responses and achieve quality, cost-effective outcomes.
Monitor and revise care plans when patient conditions change.
Complete necessary documentation and maintain clear, concise, and timely patient-record documentation of needs, post-hospital plans, resources, and patient or caregiver involvement.
Incorporate patient and caregiver treatment goals and preferences into transition-of-care planning and communicate them to the multidisciplinary team.
Follow standardized practices and processes for advance care planning, length-of-stay management, and readmission prevention.
Support denial prevention related to medical necessity by addressing or removing barriers to progression of care and participating in interdisciplinary discharge rounds.
Promote proactive care and help remove barriers to timely testing and treatment.
Ensure appropriate resource utilization and offer alternatives to acute care to the care team.
Provide clinical supervision to peers, social workers, and students.