Social Worker - Case Management

Conifer Health Solutions•Turlock, CA

About The Position

Responsible for facilitating appropriate admission types, assisting patients/families in the discharge planning process, and the identification and support of biopsychosocial, spiritual, financial, and cultural issues relevant to the patient's stay in the hospital. Supports the patient in ongoing self-care management and determination of meaningful post-acute care choices based on ongoing clinical need, safety, benefits, payment sources and patient desire. Works collaboratively with RN Clinical Care Coordinators, physicians, nursing staff, rehab team, pharmacy and lab to facilitate safe transition through acute services with appropriate lengths of stay, with successful discharges to best levels of post-acute care available to the patient.

Requirements

Licensed MSW from an accredited school or current LCSW.
Two years experience in an acute care hospital and/or skilled nursing facility.
Ability to work in a Multi-Disciplinary Team Environment.
Knowledge regarding the physical, mental and social needs of the elderly.
Ability to rotate weekends.

Responsibilities

Responsible for timely discharge planning and referrals to resources.
Responsible for protecting vulnerable persons.
Responsible for patient and family education about community resources pertinent to patient needs.
Evaluate each assigned patient, identifies social, emotional, cultural, financial and/or legal issues/problems, formulate and implement an appropriate treatment plan, provides ongoing casework and advocacy services for the patient to ameliorate medically related social or emotional problems.
Re-evaluates at appropriate intervals those patients not seen on a regular basis as well as maintaining records in accordance with the policies of the Case Management Department.
Conducts facility, telephonic and home assessments, develops care plans, outreach to members and families.
Act as a liaison/facilitator/advocate for the patient and/or family including the coordination of family and/or team conferences as needed.
Provides abuse detection and reporting, information and referral for consultation and counseling.
Participates in interdisciplinary care process, in-services and other education programs.
Assists case managers in establishing criteria to ensure appropriate level of care placements.
Maintains accurate data base information. Accurately reports interventions and outcomes. Accurately reports identified conditions utilizing condition codes.
Partners with physician to deliver the highest quality patient care by maintaining a working relationship and supporting physician’s goals and plan of care.
In conjunction with Physician, applies financial information in planning cost-effective health care without compromising quality patient care.
Give high priority to patient satisfaction by anticipating and identifying individual patient’s needs. Listens and responds with empathy to patients concerns. Takes action to meet or exceed patient’s needs. Involves patient and family as appropriate. Knowledge and sensitivity to cultural influences in response to illness.
Provides resources to advise members on coordination of benefits for Medicare and Medicaid programs.
Assist members in maintaining Medicaid eligibility.
May provide explanation of benefits for claims or cost sharing for Medicare and Medicaid programs.