Social Worker (SW) Care Transition Manager - PRN

Texas Health Resources

10d•Onsite

About The Position

Social Worker (SW) Care Transition Manager – PRN Work location: Texas Health Arlington 800 W. Randol Mill Road TX 76012 Work hours: PRN Department Highlights · Team based environment. · Workplace culture 2nd to none · We operate on lean principles and rely on team atmosphere and individual performance. · Highly engaged management What You Will Do: Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner: Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begins discharge planning. Assesses and interviews patient and caregivers as part of this evaluation and as needed. Reviews the Risk of Unplanned Readmission (RUR ) scores daily for all assigned patients. Assists in the identification of a primary care physician (PCP) for patients without a PCP and attempts to schedule follow up appointments with either a PCP, specialist, clinic, visiting physician or other transitional care visit prior to discharge. Identifies transition needs and discusses funding of post-transition care with patients and caregivers. Participates in multidisciplinary rounds (MDR?s) to help identify current length of stay (LOS), expected discharge date, anticipated discharge disposition, barriers to discharge, avoidable days, and potential denials. Coordinates/facilitates patient care progression throughout the continuum with the objective of enhancing quality clinical outcomes and safe discharge planning to the appropriate levels of care for high-risk patient populations. Coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow up. Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team. Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable Updates and executes the discharge plan as needed. Communicates final transition plan 24-48 hours prior to transition. Facilitates care conferences for complex transitions, placement, and palliative care needs. Serves as a point of contact for all identified stakeholders. Proactively identifies and documents barriers to discharge while working to resolve them, including obstacles impeding diagnostic or treatment progress. Assists patients who have complex psychosocial needs; offers solution-focused interventions to patients/families when needed. Assists with eligibility determination for funding sources and other community resources including housing, food and mental health services. Collaborates with Palliative and Pastoral Care to provide end of life and grief support and facilitates referrals to the appropriate agencies. Provides intervention in cases involving child or elder abuse/neglect. 50%25 Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source: Reviews care options and, as appropriate, utilizes existing protocols/processes to facilitate continuity of care within the Texas Health network and to ensure prompt and convenient scheduling of follow up appointments. Schedule/coordinate patient clinical needs to the appropriate post-acute care facility based on facilities? clinical capabilities/offerings, historical quality outcomes results, preferred network, and patient informed choice Identifies community resources and service needs and facilitates appropriate referrals as needed, while also providing education to patients, caregivers, and the multidisciplinary team regarding the available post-acute care services and needs. Assist with referrals for community resources including housing, food, transportation, and other social and environmental issues affecting health. Serves as a content expert regarding payor information. Educates the multidisciplinary team, patients and caregivers regarding payor requirements and barriers. Communicates with payors as needed to coordinate care. 30%25 Responsible for compliance with documentation guidelines and regulatory agency requirements: Complies with all documentation requirements and documents all activities in the electronic health record. Adheres to compliance requirements for delivery of various documents (e.g. HINN, IMM, MOON letters). Has a working knowledge of the following documents: Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate. Participates in Joint Commission and other survey readiness activities 20%25

Requirements

Master's Degree Social Work Individuals hired as a CTSW prior to May 11, 2017 will be grandfathered to the CTSW position with BSW, at the entity they were employed at on May 11, 2017. Req
3 Years in hospital/medical social work Pref and
1 Year discharge planning/care management Pref
LMSW - Licensed Master Social Worker Upon Hire Req Or
LCSW - Licensed Clinical Social Worker Upon Hire Req And
CPR - Cardiopulmonary Resuscitation Upon Hire Req
Working knowledge of medical necessity criteria preferred
Knowledge of Microsoft Outlook and Office (Word, Excel)
Customer service skills
Ability to engage in complex clinical decision-making
Strong oral and written communication skills
Strong commitment to interdisciplinary collaboration
Critical thinking, analysis and conflict resolution skills
Flexible scheduling as necessary
Psychosocial and crisis intervention skills
Ability to prioritize and meet deadlines

Nice To Haves

ACM - Accredited Case Manager Upon Hire Pref Or
CCM - Certified Case Manager Upon Hire Pref Or
Other ANCC Upon Hire Pref

Responsibilities

Responsible for ensuring patients are transitioned to appropriate levels of care in a timely and effective manner
Completes Transition Evaluations and collects Social Determinants of Health (SDOH) data on patients within 48 hours of identification and begins discharge planning.
Reviews the Risk of Unplanned Readmission (RUR ) scores daily for all assigned patients.
Assists in the identification of a primary care physician (PCP) for patients without a PCP and attempts to schedule follow up appointments with either a PCP, specialist, clinic, visiting physician or other transitional care visit prior to discharge.
Identifies transition needs and discusses funding of post-transition care with patients and caregivers.
Participates in multidisciplinary rounds (MDR?s) to help identify current length of stay (LOS), expected discharge date, anticipated discharge disposition, barriers to discharge, avoidable days, and potential denials.
Coordinates/facilitates patient care progression throughout the continuum with the objective of enhancing quality clinical outcomes and safe discharge planning to the appropriate levels of care for high-risk patient populations.
Coordinates with patients and families to manage chronic conditions and ensures appropriate post-discharge clinical follow up.
Proactively identifies patients who no longer meet continued stay criteria and communicates with the physician team.
Assigns patients to and supports appropriate transition programs (e.g. ACO members) when applicable
Updates and executes the discharge plan as needed.
Communicates final transition plan 24-48 hours prior to transition.
Facilitates care conferences for complex transitions, placement, and palliative care needs.
Serves as a point of contact for all identified stakeholders.
Proactively identifies and documents barriers to discharge while working to resolve them, including obstacles impeding diagnostic or treatment progress.
Assists patients who have complex psychosocial needs; offers solution-focused interventions to patients/families when needed.
Assists with eligibility determination for funding sources and other community resources including housing, food and mental health services.
Collaborates with Palliative and Pastoral Care to provide end of life and grief support and facilitates referrals to the appropriate agencies.
Provides intervention in cases involving child or elder abuse/neglect.
Ensures patients are provided post-acute options based on clinical necessity and patient choice while also considering the payor source
Reviews care options and, as appropriate, utilizes existing protocols/processes to facilitate continuity of care within the Texas Health network and to ensure prompt and convenient scheduling of follow up appointments.
Schedule/coordinate patient clinical needs to the appropriate post-acute care facility based on facilities? clinical capabilities/offerings, historical quality outcomes results, preferred network, and patient informed choice
Identifies community resources and service needs and facilitates appropriate referrals as needed, while also providing education to patients, caregivers, and the multidisciplinary team regarding the available post-acute care services and needs.
Assist with referrals for community resources including housing, food, transportation, and other social and environmental issues affecting health.
Serves as a content expert regarding payor information. Educates the multidisciplinary team, patients and caregivers regarding payor requirements and barriers. Communicates with payors as needed to coordinate care.
Responsible for compliance with documentation guidelines and regulatory agency requirements
Complies with all documentation requirements and documents all activities in the electronic health record.
Adheres to compliance requirements for delivery of various documents (e.g. HINN, IMM, MOON letters).
Has a working knowledge of the following documents: Advanced Directives, Medical Power of Attorney, Application for Temporary Mental Health Treatment, and out-of-hospital Do Not Resuscitate.
Participates in Joint Commission and other survey readiness activities