Case Manager Social Worker

JOB SUMMARY

The Social Worker provides services to patient, family members and/or significant others to help deal with adjustment to illness problems, understanding and accepting diagnoses, prognoses or treatment of new or recurrent disease. Provides counseling and intervention as required for cases of suspected abuse or neglect and also in cases for adoption. The Social Worker will work closely with the RN Case Manager in implementing safe and appropriate discharge plans and is the primary person responsible for coordination of complex discharge planning including placement.

PERFORMANCE DUTIES

• Uses and develops the social work process of assessment, planning, implementation and evaluation.
  • Collections and assesses data related to individual health care needs including: past medical history, current health status and treatment, necessity/appropriateness for services and setting and follow-up needed to meet needs.
  • Provides counseling to enable patient/family members and/or significant others to utilize resources and strength to make necessary adjustments due to illness, its impact and changes to be anticipated.
  • Is an active participant in multidisciplinary rounds.
  • Communicates daily with RN Case Managers and RN’s on their assigned unit to case find appropriate referrals.
  • Identifies the need for and convenes family meetings to provide clarity to the patient’s status that result in informed decision making.
  • Formulates discharge plans by collaborating with the patient/family, healthcare team members and outside agencies. These may include new oncology diagnoses, patients with difficult family dynamics, hospice patients, patients facing end of life issues, placement issues such as ECF or Rehab and other patients to meet the need of the case management team.
  • Affords assistance in coordinating with the physician, nurse manager and case manager to implement a safe plan of care for child if there are concerns regarding abuse/neglect. Coordinates with the physician, nurse manager and case manager to implement a safe plan of care for an adult. Coordinates with the domestic violence service agency to plan counseling service and/or a shelter placement, if necessary.
• Documents in patient’s electronic data base ongoing communication with all individuals responsible for the continuum of care or regulatory issues.
• Demonstrates the ability to use the various computer programs required.
• Conducts support/education groups to assist in adjustment process. As appropriate, may have the option to facilitate either a time limited or ongoing group process to help family members cope with illness, as time permits.
• Handles community calls and visits.
• Provides on-call coverage for social work interventions on Sundays and Holidays, this may include acting as a resource for directing urgent need for DME or HHC if no Case Manager is available.

OTHER DUTIES

• Develops and maintains positive, effective communication skills in all interactions.
• Analyzes and applies appropriate communication style for each situation.
• Participates in team meetings daily.
• Participates in the educational process of various co-workers, orientees and other departments as related to Social Work functions.
• Demonstrates awareness of and adherence to safety and legal requirements established at hospital and departmental levels.
• Aids in the planning and implementation of departmental based quality management and disaster response activities.
• Compliant with HIPPA standards.
• Accepts accountability and responsibility for own professional growth and development.
• Promotes an environment that allows for positive, effective areas of practice for all “customers” of Outcomes Management.
• Remains current on trends in own practice and in areas that involve the department and facility.
• Maintains current, active status in profession and meets continuing education standards set by the department and/or facility.
• Serves on committees, task forces and focus or work groups on a voluntary and/or appointed basis at the staff/department level.