Complex Inpatient Medical Social Worker

About the role

Make a meaningful difference every day by supporting patients with the most complex psychosocial and care-transition needs. As a Complex Inpatient Medical Social Worker, you will serve as an expert resource, guiding patients, families, and clinical partners through challenging circumstances while ensuring safe, effective, and timely transitions across the care continuum.

Responsibilities

• Provides care management/social work services to Complex patients, families, and individuals including perming thorough patient psychosocial assessments, screening, determination of needs evaluation, appropriate interventions and follow up, and discharge planning.
• Implements targeted interventions and patient-family centered care plans to achieve optimal health outcomes.
• Collaborates and negotiates effectively with socially complex patients, family and the clinical team while striving to achieve patient and organizational goals regarding care needs, choices, and satisfaction during discharge planning and care transitions.
• Offers coordinated, relevant options and services based on assessed needs to ensure patient, families, and the healthcare team are informed and prepared to proceed with accountabilities in a timely manner.
• Participates in the communication processes to facilitate smooth transitions for patients, families, and staff during patient transfers.
• Participates in multidisciplinary rounds and work closely with clinical team members, hospital departments and ancillary services to identify and resolve barriers to discharge, expedite care delivery to avoid delays in timely service provision, and implement and report on care coordination and discharge planning.
• Collaborates and leads discussions with managers, physicians, medical directors, advisory groups, and treatment teams for issues related to physician practices and best practices for patient care plans.
• Refers cases to physician advisors as needed to ensure efficient progression of care, accurate status, and compliance with regulatory guidelines.
• Maintains knowledge of healthcare regulations, reimbursement issues, impact on length of stay and community-based resources.
• Develops and maintains productive relationships with community-based agencies, particularly those serving socially complex patients.
• Serves as a leader in the multi-disciplinary health care team to develop safe and timely coordination of care including but not limited to post-acute placement, palliative/hospice service lines, medical equipment, home healthcare, outpatient follow up, mental health resources, and other community resources.
• Advocates for patient involvement in the plan of care. Initiates and coordinates interventions with the activities of other members of the health care team.
• Serves as a leader to follow up with internal partners, such as financial advocates, Patient Access, Level II assessors, and other multi-disciplinary teammates to drive optimal results and reduce delays in patient throughput.
• Maintains up-to-date knowledge of community resources, legislation, and regulations impacting health care delivery and educating patients and families on these issues as appropriate.
• Provides resources to patients and families to ensure a timely discharge and to provide an appropriate link with post-acute care providers and services.
• Provides support and connection to additional services such as bereavement and loss, ethical issues, advanced directives, and end of life issues.
• Collaborates with community agencies and institutions to plan continued care and to coordinate interventions.
• Provides resources and education to patients and families regarding appropriate resources and access to community social services.
• Provides education to patients/families regarding Advance Directives for health care decision-making.
• Assists with execution of these documents as appropriate.
• Manages the progression of patients stay with the goal of optimizing the LOS and ensuring appropriateness of assigned Level of Care.
• Manages the patient’s care across the continuum to decrease unnecessary readmissions.
• Manages and coordinates patient care within an ACO environment to help facilitate patient outcomes through in network care coordination.
• Accountable for site specific KRA goal achievement as it relates to Care Coordination across the continuum.
• Participates in the orientation of new staff and/or education of social work students.
• Aggregates, analyzes, interprets and reports data on patient outcomes and resource utilization.
• Facilitates reporting of utilization monitoring and review activities to relevant committees and stakeholders.

Requirements

• Education: Master’s Degree in Social Work
• Certification / Registration / License: License NC & GA (Division: No license required)
• Professional Standards: Maintains professional standards and responsibilities for his/her own professional practice according to accreditation, hospital, system, state and NASW Standards and Code of Ethics.
• Continuing Education: Completes all required continuing education to maintain licensure and increase knowledge within area of practice specialty.

Qualifications

• Experience: 3 years of hospital care management experience.
• Knowledge / Skills / Abilities: Ability to prioritize and organize work.Effective communication skills.Utilization of critical thinking and timely decision making.Ability to navigate the electronic health record.Basic utilization of MS Office products.Knowledge of Medicare A and B guidelines.Knowledge of managed care program requirements/implications.Ability to apply elements of utilization management programs.

Skills

• Ability to prioritize and organize work.
• Effective communication skills.
• Utilization of critical thinking and timely decision making.
• Basic utilization of MS Office products.
• Knowledge of Medicare A and B guidelines.
• Knowledge of managed care program requirements/implications.
• Ability to apply elements of utilization management programs.

Benefits

Comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

• Compensation
• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Education Assistance Program