Care Management/Medical Social Work

Job Summary

Responsible for identifying and interacting with medically and psychosocially complex patients and families who are likely to benefit from care management and meeting high risk criteria. Coordinates discharge planning services for these patients in collaboration with RN Care Management and other members of the care team.

Details of the Position

• Screen and identify patients who need care management per high-risk criteria.
• Assess, develop, implement and monitor a comprehensive discharge plan of care through an interdisciplinary team process in conjunction with the patient and family.
• Collaborate with the multi-disciplinary team to identify problems or needs that require special planning, intervention, teaching or follow-up.
• Identify key problems, strengths and resources to be addressed in the discharge plan of care.
• Cook up and facilitate improved ability to comply with plan of treatment; counseling or support needed to cope with situation; improved ability to access appropriate level of care due to lack of financial resources or lack of available service.
• Actively support measures that promote effective use of resources.
• Identify, plan and arrange for appropriate services applying a knowledge of services available in the community, state, and federal health regulations and admission, discharge and appropriate level of care.
• Cook up effective planning and arranging for needed services upon discharge.
• Intervene by arranging services, education and providing psychosocial support to prepare the patient and their family to manage their healthcare needs within the acute care setting and post discharge.
• Cook with the interdisciplinary team and community resources when appropriate, regarding the multiple details of transitional care management plan.
• Consult with physician as indicated.
• Works with patients identified and referred to them by RN Care Management and/or other members of the care team, as well as by patients/families.
• Conducts evaluation to include appropriate documentation and the effectiveness of the Care Management services.
• Collaborates with team members to identify cause and adjust plan if patient’s health status is not improving.
• Makes sure to counsel patients and/or families to facilitate and/or participate in community care services, in coordination with the physician and treatment team.
• Works as an integral member of the treatment team in the coordination of treatment and transition of care planning.
• Assesses and addresses both mental health and chemical dependency conditions.
• May perform risk assessments for suicidality and homicidality.
• Performs other duties as assigned.

  What You Bring

  • Bachelor's Degree Required: Social Work or in a related field, with a minimum of four additional years' work experience in a medical or healthcare setting, social service agency, or community organization focusing on health and/or welfare issues.
  • Master's Degree Required: Social Work, Counseling, or related field.
  • Minimum of 2 years Preferred: employment in a healthcare setting or community agency dealing with health and/or welfare issues.
  • Preferred: Certified Case Manager.
  • Preferred: Licensed Clinical Social Worker - Oregon (Oregon Requirement).

  Skills

  • Excellent verbal and written communication skills including sensitivity to other cultures and ethnicities.
  • Excellent skills in conceptual thinking, listening, problem resolution and planning.
  • Demonstrated leadership skills.
  • Excellent organizational skills.
  • Proficient computer skills including MS Office applications and electronic medical records.
  • Knowledgeable about issues related to chronic illness, developmental disabilities, special needs, mental illness, grief and transition, substance abuse, domestic violence, child abuse and senior abuse.
  • Demonstrated knowledge of community health, welfare, and social agencies.
  • Demonstrated knowledge of and ability to apply age specific principles of growth and development and life stages to meet each patient’s needs.
  • Demonstrated proficiency in social work practice.

  Working Conditions

  • Lifting Ability to move around area with occasional sitting.
  • Bend/ twist/ reach/ push/ pull occasionally.
  • Lift/Carry: Occasionally up to 5 lbs.

  Environmental Conditions

  • Exposure to biohazard, body fluids and airborne particles.
  • Time spent on site in medical/hospital setting or in office environment.

  Mental/Visual Vision and hearing required within normal limits (glasses, contacts, hearing aids permitted).

  • Ability to communicate and exchange accurate information.

  Benefits

  • 403b retirement plan for caregiver contributions.
  • Wellness benefits.
  • Discount program.
  • Expanded EAP and mental health program.