Social Worker Case Manager - Adult Congenital Heart Disease
About The Position
The Social Worker Case Manager 1 supports Inova’s Adult Congenital Heart Disease program at Willow Oaks. This full-time role evaluates patients’ ability to progress through the continuum of care and collaborates with physicians, nursing staff, and other multidisciplinary care team members to support timely and appropriate patient management. The position requires working knowledge of utilization management, managed care, and payer issues. The role provides discharge planning and continuity of care for assigned patients in acute and post-acute settings, including coordination of services and referrals to appropriate resources. The Social Worker Case Manager serves as a liaison among patients, families, and interdisciplinary healthcare team members, supporting care transitions and ongoing community care.
Requirements
- Master’s degree in Social Work (MSW).
- At least 1 year of experience in clinical care or clinical case management.
- Basic Life Support certification upon start.
Responsibilities
- Participate in assessing patients’ biopsychosocial needs by reviewing patient information and communicating with patients, families, and interdisciplinary care team members.
- Communicate routinely about care-plan status, progress toward treatment goals, concerns, problem-solving, and conflict resolution.
- Ensure available transition options and care-plan requirements are communicated to patients, families, and healthcare team members and documented as needed for continuity of care.
- Refer cases and issues as appropriate to resolve barriers to care progression and advocate for patients facing those barriers.
- Assess psychosocial risk factors based on preliminary risk screenings, including prior functional levels, adequacy of support systems, reactions to illness, and ability to cope.
- Intervene with patients and families regarding the emotional, social, and financial consequences of illness or disability.
- Provide counseling and interventions related to treatment and end-of-life decisions, and support patient and family autonomy in healthcare decisions and access to services.
- Provide discharge planning and continuity of care in acute and post-acute settings.
- Initiate and facilitate referrals to clinics, home healthcare, hospice, skilled nursing facilities, acute rehabilitation, LTAC, TCM, and medical equipment and supplies as indicated.
- Coordinate discharge planning and post-discharge services with the interdisciplinary care team, patients, and families, including transitions from hospital to discharge setting and ongoing community care.
- Document relevant discharge-planning information in the medical record according to department standards and/or care management plans.
- Collaborate and communicate with internal and external case managers.
- Coordinate services and act as a liaison between patients, families, and interdisciplinary healthcare members.
- Perform other duties as assigned.
Benefits
- Medical, dental, and vision coverage.
- Team member wellness program.
- Inova matches the first 5% of eligible retirement contributions, starting on the first day.
- Education assistance of up to $5,250 per year.
- Student loan assistance of up to $10,000.
- Up to 25 mental health coaching or therapy sessions per person, per year, at no cost, for team members, their spouses or partners, and their children.
- Paid time off.
- Paid parental leave.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
