SW Transitions And Care Coordinator Full Time

Cape Fear Valley Health

33d•Hybrid

About The Position

Provides CAP case management that consists of assessing, care planning, referral and linkage, monitoring and regular follow up. Case managers will identify needed medical, social, environmental, financial, and emotional interventions. Responsible for overseeing the maintenance of community integration while ensuring the beneficiary’s health, safety and wellbeing. Consistently communicate with local, region and state resources to ensure mental, spiritual, medical and social needs are met. Required to provide crisis interventions to encourage adherence to long term medical and mental health care.

Requirements

Master’s degree in Social Work (MSW) required
1 year previous experience in medical social work, case management, disease management transitions coordination, or care coordination required
Proficiency in reading, writing, and speaking the English language
Ability to work with high degree of independence, demonstrating personal accountability, responsibility for performance improvement and high professional growth
Positive interpersonal skills with excellent communication, problem solving and negotiation skills
Strong organizational skills, critical thinking skills, and the ability to appropriately prioritize direct case management, patient/family support and other duties
Knowledge of Erickson’s developmental model and ability to demonstrate age specific interventions
Knowledgeable and sensitive to the psychosocial spiritual and cultural needs of individuals
Articulate orally and in written communication and ability to make accommodations for literacy and comprehension levels
Ability to use own transportation to make home visits and to carry out duties away from the office
Visual acuity to see and read medical records documents, computer screens and computer printouts
Speech and auditory abilities are required to allow for effective communication
Ambulate, climb stairs and push or pull wheelchair patients at times
Ability to lift, load/unload client care supplies/equipment up to 30 pounds
Position may involve contact with blood or potentially infectious material
CCM - Commission For Case Manager Certification

Nice To Haves

National Certification in Case Management or Licensed Clinical Social Worker preferred
Maintain State requirements for population served when performing CAP/DA, CAP/C, CAP/Choice or MFP transitions or case management required

Responsibilities

Provides case management and care coordination activities to assigned caseload in a manner that maximizes patient satisfaction, provider satisfaction and client centered outcomes
Coordinates Money Follows the Person Transitions as well as Community Transitions such that the length of stay in acute care, or other qualifying level of care is reduced, appropriate supports are put in place, and readmissions are avoided
Performs comprehensive interdisciplinary needs assessments for the assigned CAP beneficiaries monthly
Formulates the plan of care in collaboration with the beneficiary and support persons with the service plan specifying person-centered goals, objectives, and formal as well as informal support services to address identified medical and functional care needs
Provides follow-up visits and/or other support to beneficiaries who have been discharged from acute care or SNF to reduce the possibility of readmission
Provides referral and linkage activities to connect a beneficiary or caregiver with medical, behavioral, social, and other programs, services and supports to mitigate identified needs and achieve whole person-centered goals
Completes documentation via eCAP internet- based program
Responsible for SBARR communication with acute care staff when CAP beneficiaries are hospitalized and performs as a liaison for discharge planning as needed
Develop resources to serve the assigned population through grants, networking with outside agencies and other departments within the Health System and through other approved means
Other duties as assigned