The Social Worker Care Manager provides appropriate interventions and discharge planning services to patients and families, facilitating smooth 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 and prioritizes patients who need social services through a holistic approach that considers biopsychosocial, functional, cultural, spiritual, and financial factors. The Care Manager plans with patients, caregivers, and the healthcare team to support quality, effective, and cost-conscious outcomes, and monitors and revises plans as patient conditions change. The role maintains timely and complete documentation of patient needs, care plans, post-hospital resources, and patient or caregiver participation, while ensuring their goals and preferences are incorporated into transition planning and shared with the multidisciplinary team. The Care Manager follows standardized practices for Advance Care Planning, length-of-stay management, and readmission prevention. The role supports medical-necessity denial prevention by addressing barriers to progression of care and participating in interdisciplinary discharge rounds. It also promotes proactive care, helps remove barriers to timely testing and treatment, ensures appropriate resource use, and offers alternatives to acute care to the care team.
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Job Type
Full-time
Career Level
Mid Level