Social Worker Case Manager - MSW, Care Coordination, Full-Time, Days

MarinHealth Medical Center•Bon Air, CA

2d•Onsite

About The Position

The Social Work (SW) Case Manager, in collaboration with members of the inter-disciplinary healthcare team, leads the development and implementation of the multidisciplinary plan of care for patients, determining appropriate patient status and level of care; ensuring effective quality and cost-efficient outcomes, and supervising the provision of the discharge plan of care. This position functions as the key linkage between the physician, staff, and hospital leadership in the day-to-day management of appropriate and efficient patient care and functions as an advisor to the physician with accountability to escalate cases to the Manager, Director, or Physician Advisor (as necessary) to ensure the provision of appropriate and effective patient care.

Requirements

Master's degree from an accredited school of social work or social welfare required.
Prior work experience in a healthcare environment is required.
Acute care hospital experience or recent internship strongly preferred.
Associate Clinical Social Worker (ACSW) within 90 days of hire.
Basic Life Support (BLS) required within 90 days of hire.
Integrative Agitation Management (IAMTAC) required within 30 days of hire.
Must have the ability to read, write, and follow English verbal and written instructions, and have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills.
Adhere to the professional ethics, practice, and Values ad delineated by the National Association of Social Workers (NASW) Code of Ethics.
Leadership skills to delegate, functionally supervise, provide direction/guidance to staff and hold others accountable are required.
Must have the ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities.
Must have strong clinical assessment and critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs.
Strong attention to detail and accuracy is required.
Must have the ability to work in a high volume case load environment and deal effectively with rapidly changing priorities.
Demonstrated ability to work constructively with a broad spectrum of health care professionals is required.
Must be assertive and creative in problem solving, system planning, and management.
Proficient computer skills are required, including the use of Electronic Health Record and other IT applications.
General knowledge of supervisory principles/applications is required.
Must have a working knowledge of disease processes, current treatments and their physical and psychosocial sequelae.
Knowledge of individual and family development over the life span is required.
Knowledge of the influence of cultural and spiritual values on health care is required.
Basic knowledge of applicable laws, regulations, and accreditation guidelines (e.g., CMS, DHCS, The Joint Commission, EMTALA, Title 22, and DOJ) is required.
Basic knowledge of government and private insurance benefits (e.g. Medi-Cal, Medicare, DRGs, managed care, capitation), including reimbursement requirements is needed.
Must know child, elder and dependent adult and domestic violence reporting requirements.
General knowledge of available health care and community resources appropriate for populations served is required, broad/in-depth knowledge is preferred.
Working knowledge of Inter-Qual criteria.

Nice To Haves

Accredited Case Manager (ACM-SW) preferred at hire.
Certified Social Work Case Manager (C-SWCM) preferred at hire.
Acute care hospital experience or recent internship strongly preferred.

Responsibilities

Coordinates care for an assigned unit paired team model comprised of SW Case Manager, RN Case Manager, and Case Management Specialist.
Works with the multi-disciplinary healthcare team to ensure the plan of care is expedited and barriers to efficient throughput are identified and corrected.
Creates a plan of care that outlines the key interventions and outcomes to be achieved during the inpatient stay.
Can actively lead multidisciplinary case conferences in developing comprehensive, cost-effective case management plans that span the continuum.
Makes independent assessments and recommendations regarding course of action in complex situations and recommendations relevant to multi-system or special needs patients.
Identifies and refers quality and risk management concerns to appropriate level for corrective action plans and trending.
Proactively solicits physician’s orders for services.
Demonstrates knowledge and skills necessary to provide cultural, spiritual and age specific care by obtaining specific psychosocial information and assessing relevant information needed to identify each patient’s unique treatment and discharge planning needs.
Provides psychosocial assessments and treatment to patients and or families related to adjustment to illness and discharge planning.
Demonstrates knowledge and skills necessary to provide cultural, spiritual and age specific care by obtaining specific care information and assessing relevant information needed to identify each patient’s unique treatment and discharge planning needs.
Performs unit/department/program specific comprehensive psychosocial assessments, ensuring pediatric, adult and elderly patient’s age-related needs and coping mechanisms are clearly identified.
Acts as patient advocate and resource regarding patient’s needs including financial considerations.
Possesses clinical expertise to effectively assess, coordinate, implement and evaluate all services required to meet the needs of the patient.
Provides individual, conjoint family and group therapy as appropriate to setting.
Maintains effective communications with staff and attending physicians related to patient’s psychosocial and psychiatric needs.
Maintains open communication and positive working relationships with all hospital departments as well as adheres to hospital chain of command.
Willing to assist others and supports other hospital personnel in providing optimal patient care.
Demonstrates a clear understanding and adheres to designated unit/department/program as well as overall policy and procedure.
Collaborates with physicians, patients, families and treatment team members in the development of the patient’s plan of care.
Assist and promotes patient/family education and ensures that the patient’s educational needs are being met.
Works with public and private sectors (i.e. public guardian’s office) to ensure best treatment outcomes as well as completes necessary documents consistent with Clinical Social Worker scope of practice.
Ensures proper content, application, and submission of required legal documents impacting patient care and treatment outcomes (i.e. LPS, Probate, mandated reporting).
Provides clinical information for placement and referral to outside agencies consistent with HIPAA and state guidelines for special needs populations.
Interprets and cites applicable laws and regulations to staff and physicians pertinent to individual patient needs.
Participates in meetings and committees relevant to specific treatment area/department/program and represents MarinHealth Medical Center at relevant community meetings and committees.
Provides psychosocial education and perspective to other healthcare professionals, including nursing students or any other healthcare related practice, as indicated.
Reviews initial hospital admission and gathers additional medical, psychosocial and financial data from needs assessment, client/family, physicians, and other health care providers.
Initiates discharge planning at the time of admission.
Formulates a discharge plan after completing a face-to-face interview and discusses available/appropriate care options and obtaining input from the patient/family and physician, healthcare team, insurance companies, and community-based support services.
Maintains and provides current information and referral services to patients, caretakers and families related to appropriate community resources and agencies.
Independently case finds, coordinates and implements discharge plans for all patients with psychosocial needs.
Maintains knowledge of current eligibility criteria for a wide array of community resources.
Maintains positive working relationships with community agencies.
Utilizes and expands knowledge base of community resources.
Initiates contact with state, county and private resources, including family, to facilitate discharge to the least restrictive level of care.
Provides advocacy for clients in accessing appropriate community-based resources.
Collaborates with physicians to facilitate timely resolution of situations such as client concerns, need for referrals and discharge barriers to expedite the discharge plan.
Acts as a resource and content expert for the physicians regarding an optimal care plan for patients.
Identifies potential problems, prevents and/or resolves variances to the case management plan.
Effectively deals with resistance and conflict in working with member of the patient care team, physicians, clients, and families.
Implements all aspects of the discharge plan of care, intervening in an appropriate and timely basis when difficulties arise. This may require documentation and follow-up with other management staff to ensure effective resolution.
Provides accurate, clear, concise, relevant and timely documentation in patient’s charts accordingly to individual units/departments/programs documentation system and their adherence to specific CMS and State regulations and in accordance with policy and procedure.
Maintains consistent and clear documentation on daily assessment of patients related to care plan.
Documents timely initial psychosocial assessment according to unit/department/program’s standard of care.
Documents all collateral contracts.
Documents all screening and clinical interventions (i.e., SBIRT, AUDIT, DAST, CAGE, C-SSRS/SAFE-T, ITSS).
Documents all discharge planning efforts, including timely insurance reviews.
Documents treatment planning according to each units/departments/program standards by using each unit/departments/programs specific forms.
Maintains confidentiality of privileged communication with patients and families adhering to Clinical Social Work Practice standards.
Actively participates in department meetings and operations, including process development or improvement (e.g., department orientation, internal mentor/training programs and initiates, disease and population management strategies, appropriate measures for evaluation of outcomes) and establishment of department goals, objectives, and budget.
Ensures all applicable department and regulatory targets for productivity and department performance process improvement are attained (e.g., hospital length of stay, average cost per discharge, and re-admission rates, etc.).
Complies with all reporting requirements for mandated, risk management, and other medical/legal situations consistent with confidentiality policies and department standards.
Actively contributes to the development and maintenance of a care delivery system which is sensitive to individual patient needs, promotes effective resource utilization, and supports physician practice, while emphasizing coordination across the continuum.
Positively contributes to team’s decision-making process, effectively collaborates with other team members on interdependent tasks, and actively supports implementation of plans to accomplish team objectives.
Prepares and conducts presentations to multidisciplinary teams related to special projects, case management, etc.
Adheres to department and facility policies and procedures and supports philosophies and initiatives.
Maintains accurate, current, and legible patient records using approved forms and format, according to department and entity standards, including patient assessments, plans, interventions, patient/family involvement, outside agency communications, and interdisciplinary contacts.
Other duties as assigned