Care Management Social Worker

About the role

Assesses patients’ and families’ wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.

Responsibilities

• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
• Communicates with Payors patient’s needs for authorization for post-acute care as needed.
• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.
• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Assesses readmitted patients for the patient’s and family’s perceived reasons for the readmission.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Provides patient and family advocacy, and support patient’s choice and patient rights during hospitalization.
• Other duties as assigned.

Qualifications

• Master's in social work [Required]
• 2+ social work [Required]
• Experience in acute care setting preferred

Licenses and certifications

• Clinical Social Worker License (LCSW) [Required] OR
• Licensed Mental Health Counselor (LMHC) [Required]

Schedule

Full time. 8AM - 6:30PM weekdays and every other weekend.

Pay

$49,307.53 - $91,705.34