CASE MANAGER SOCIAL WORKER -

About the role

Department: Hospice Care-Pediatric
FTE: 1.00
Full Time
Shift: Days

Responsibilities

• PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable
• IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral
• CASE MANAGEMENT - Provide case management and discharge planning services in a timely and cost-effective manner to include patient assessment, planning, implementation, coordination, monitoring and evaluation
• ASSESSMENT - Complete psychosocial assessment of identified patients whose medical status, recovery, or timely discharge may be impeded by inadequate social, environmental, or economic conditions, by inadequate funding sources, and/or by impaired emotional or cognitive status including decisional incapacity
• ASSESSMENT - Assess patient level of functioning, including developmental, physical, environmental, cognitive, behavioral, psychological, economic, social, cultural and spiritual factors
• PATIENT ASSISTANCE - Provide assistance to facilitate patient recovery, discharge and/or management of an acute, chronic or terminal illness or condition; assistance may include education, community referrals, advocacy, and mediation with patients and families to assist in adjustment to changes in health status and functioning expediting timely discharge to an appropriate level of care
• OUTCOMES - Identify patients with a history of medical non-compliance, high resource utilization and poor outcomes; monitor patient outcomes, re-evaluate plans of care to accommodate changes in treatment or progress
• GOALS & OBJECTIVES - Assist in resolution of identified barriers and develop alternative goals and objectives with patients and family members
• DOCUMENTATION - Document assessment data, patient problems, interventions taken to achieve outcomes and evaluation of patient progress toward targeted outcomes
• LIAISON - Serve as UNMHSC liaison to state protection agencies for all reports and/or concerns of patient abuse, neglect or exploitation
• LEGAL COORDINATION - Coordinate with UNMHSC Office of Legal Counsel regarding matters involving treatment guardianship and/or other legal issues
• COMMUNICATION - Use effective communication strategies with patients, families, physicians, nurses, allied professionals and others to achieve desired patient outcomes and patient satisfaction
• CARE COORDINATION - Coordinate multidisciplinary care planning, including patient care conferences as appropriate to facilitate resolution of treatment decisions and timely discharge planning
• RELATIONS - Develop and maintain positive relationships with community agencies and third party payor sources
• EDUCATION - Contribute to education of physicians, nurses, allied health professionals and students
• RESOURCE - Acts as resource to professional colleagues; provide staff training, development and consultation as appropriate
• DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
• PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
• PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
• PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
• PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
• PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"

Qualifications

• Education: Essential - Master's Degree
  Education specialization: Essential - Related Discipline
• Experience: Essential - No minimum experience required
  Nonessential - Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo
• Credentials: Essential - NM LMSW or LPC or LCSW
  Nonessential - Licensed Clinical Social Worker in New Mexico
  Licensed Master's Social Worker in New Mexico
• Physical Conditions: Sedentary Work