Social Worker-Relief

Adventist Health • Shawnee, KS

76d

About The Position

The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Social Worker is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Work Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Social Work Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

Requirements

• Masters in Social Work (MSW)
• Minimum three (3) years experience in hospital/medical social work
• Care Management discharge planning experience
• Knowledge of state and federal guidelines pertinent to care management
• Licensed Clinical Social Worker (LCSW)
• ACM/CCM certification

Nice To Haves

• Excellent interpersonal communication and negotiation skills
• Critical thinking and problem-solving skills
• Psychosocial assessment skills
• Customer service skills
• Ability to work and communicate with people of all social, economic, and cultural backgrounds
• Effective organizational skills
• Computer proficiency with Outlook e-mail and electronic medical records
• Understanding of pre-acute and post-acute venues of care and post-acute community resources
• Strong interview, assessment, and organizational skills
• Leadership skills
• Data analysis skills

Responsibilities

• Assesses patient's and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems.
• Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability.
• Serves as a resource to provide information and intervention related to treatment decisions, terminal illnesses and end-of-life issues.
• Provides grief counseling and crisis intervention skills.
• Advocates for patient and family empowerment and independence to make autonomous health care decisions.
• Provides de-escalation services for patient/family as appropriate.
• Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention.
• Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers.
• Receives referrals for psychosocial complex needs from the health care team.
• Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.
• Facilitates full team discussion including patient and family when ethical dilemmas arise.
• Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission.
• Incorporates the patient/family care goals and preferences into the transition of care planning.
• Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
• Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds.
• Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care.
• Ensures patient notifications are provided and documented in a timely manner for compliance.
• Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
• Participates in department and hospital Performance Improvement activities.

Benefits

• Vision, Medical & Dental Benefits from Day One
• Student Loan Repayment Program

What This Job Offers

• Career Level: Mid Level
• Education Level: Master's degree
• Number of Employees: 5,001-10,000 employees