Care Management/Medical Social Work - Care Management

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 based on 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.
• Cookordinate 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.
• Cookordinate 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.
• Cookordinate 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.
• Cooklaborates with team members to identify cause and adjust plan if patient’s health status is not improving.
• May 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.