SW Case Manager II

Chesapeake Regional Healthcare•Chesapeake, VA

About The Position

The Social Worker Case Manager II is a key member of the Care Management team, coordinating patient care across the continuum. The role combines clinical social work expertise with knowledge of post-acute care needs, behavioral health, and community resources to support safe, timely, and cost-effective transitions of care. The position applies discharge-planning, quality-management, and resource-utilization principles while working with a multidisciplinary team to achieve optimal patient outcomes. The Social Worker Case Manager assesses patients’ psychosocial, functional, legal/financial, and safety status; develops and implements individualized discharge plans; coordinates referrals and community resources; and identifies and addresses discharge barriers. The role partners continuously with RN Case Managers, physicians, nurses, ancillary staff, insurers, patients, families, and community agencies. It monitors length of stay and resource utilization, supports post-acute activities, documents discharge plans and related information, and participates in performance-improvement work. The position also conducts readmission interviews, serves on committees, and acts as a preceptor and mentor. The employee is expected to become proficient in assigned responsibilities within 90 days. The position requires a Master of Social Work, at least two years of clinical social work experience, and at least one year of case management experience in an acute or post-acute setting. Active CPR certification is required, as is obtaining an ACMA or CCM Case Management Certification within two years of hire. The role works within CMSA Standards of Practice and adheres to the NASW Code of Ethics. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Requirements

Master of Social Work.
At least two years of clinical social work experience.
At least one year of Case Management experience in an acute or post-acute setting, such as an acute care hospital, post-acute rehabilitation, home health, or community nursing setting.
Active CPR certification and compliance with hospital renewal policy, including the RQI policy.
Obtain Case Management Certification (ACMA or CCM) within two years of hire.
Become proficient in assigned job responsibilities within 90 days.
Ability to perform the essential duties satisfactorily; reasonable accommodations may be made for individuals with disabilities.

Responsibilities

Interpret, analyze, and apply psychosocial and clinical data to prioritize and determine appropriate patient-management actions.
Communicate and collaborate effectively using culturally and professionally appropriate interpersonal skills.
Manage time effectively and carry out job responsibilities and organizational requirements in a timely manner.
Assess, plan, implement, and evaluate strategies for appropriate use of community and psychosocial resources and management of length of stay.
Assess, plan, implement, and evaluate discharge plans for the assigned patient caseload.
Create and implement a discharge plan for every admitted patient, tailored to each patient's needs and problems.
Assess patients’ psychosocial, functional, legal/financial, and safety status, including self-care and environmental factors.
Collaborate with physicians, nurses, ancillary staff, multidisciplinary team members, and community resources to recommend appropriate patient management.
Comanage patient caseloads continuously in partnership with RN Case Managers.
Identify and address patients’ and families’ social determinants of health needs and refer them to appropriate community, caregiver, behavioral health, psychosocial, transportation, medical, housing, and educational resources.
Implement discharge plans and referrals to services.
Identify and resolve delays and obstacles to discharge; lead and advocate in the discharge-planning process.
Monitor patient length of stay and resource utilization; identify avoidable days and process-improvement opportunities and recommend actions to improve efficiency and resource use.
Communicate through the chain of command regarding resource utilization, psychosocial concerns, and discharge barriers.
Provide information regarding denials and approvals; communicate denials for post-acute services to patients, families, and physicians as needed.
Collaborate with physicians, RN Case Managers, and insurance companies to support post-acute activities.
Enter pertinent discharge-plan data into designated collection systems according to policy and established processes.
Participate in clinical performance-improvement activities as needed and assigned.
Conduct readmission interviews with patients and families to help determine psychosocial causes of readmission and enter information into appropriate systems.
Interpret and negotiate with state, local, and federal agencies to support placement in the most appropriate setting.
Align patient needs with placement options consistent with the desired level of care.
Work within CMSA Standards of Practice and adhere to the NASW Code of Ethics.
Serve on committees supporting organizational and departmental operations and practices.
Serve as a preceptor for new hires and mentor other Case Managers.
Demonstrate initiative in establishing and achieving personal and professional goals and provide customer service consistent with the organization’s mission, vision, and values.
Perform other duties as assigned.