Care Management Social Worker

About the role

Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate.

Affords patients and families emotional, social, and financial support, mobilizes family/community resources, and advocates for patient and family empowerment in health care decisions.

Communicates with payors to secure authorization for post-acute care as needed.

Assesses readmitted patients for perceived reasons for readmission.

Responsibilities

• Assesses patients and families for discharge planning needs in inpatient, observation, and emergency departments, incorporating clinical, social, and financial factors.
• Develops discharge plans with contingency plans throughout the hospital stay, ensuring timely care coordination and progression of care.
• Reviews medical records, including medications, history and physical, labs, and progress notes, to inform the transition of care plan.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities for continuity of care, ensuring complete medical records and accurate discharge reconciliation.
• Participates in multi-disciplinary rounds to review patient status, progression, and level of care, and discharge plans, identifying necessary resources and escalating care delays to leadership as needed.
• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness, mobilizing family/community resources to meet identified needs.
• Documents discharge planning evaluations, ongoing assessments, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Provides patient and family advocacy, supports patient’s choice and rights during hospitalization, and communicates with payors for authorization of post-acute care as needed.
• Assesses readmitted patients for their perceived reasons for readmission, and coordinates with the multidisciplinary team to facilitate a timely transition.

Requirements

Master's degree in a related field [Required]

2+ years of care management experience [Preferred]

2+ years of social work experience [Required]

Skills and Abilities

• Excellent interpersonal communication and negotiation skills [Required]
• Critical thinking and problem-solving skills [Required]
• Pychosocial assessment skills [Required]
• Customer service skills [Required]
• Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change [Required]
• Effective organizational skills [Required]
• Computer proficiency with Outlook e-mail and electronic medical records [Required]
• Flexible in a complex and changing healthcare environment [Required]
• Understanding of pre-acute and post-acute venues of care and post-acute community resources [Required]
• Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources [Required]
• Strong interview, assessment, and organizational skills [Required]
• Leadership skills [Required]
• Data analysis skills [Required]
• Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement [Preferred]
• Knowledge of state and federal guidelines pertinent to Care Management [Preferred]
• Ability to identify appropriate community resources and to work collaboratively with patients, families, multidisciplinary team and community agencies to achieve desired patient outcomes [Preferred]
• Knowledge of state and federal guidelines pertinent to care management [Preferred]

Qualifications

Accredited Case Manager (ACM) [Preferred]

Certified Case Manager (CCM) [Preferred]

Physical Requirements: (Please click the link below to view work requirements)

Physical Requirements

Benefits

Commensurate with experience

Schedule

Full time

Pay

$23.71 - $44.09