FT SW Care Manager

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.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities, ensuring patient care information is communicated for continuity of care.
• Participates in multi-disciplinary rounds to review changes in patient status, progression, and level of care, and discharge plans for all assigned patients.
• Facilitates patient and family care conferences with the multidisciplinary team, documenting discharge planning evaluations, ongoing assessments, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Documents and communicates with payors for authorization of post-acute care services as needed.
• Assesses readmitted patients for the patient and family's perceived reasons for readmission.

Requirements

Master's degree in a related field [Required]

2+ years of care management experience [Preferred]

2+ years of social work experience [Required]

Accredited Case Manager (ACM) [Preferred]

Certified Case Manager (CCM) [Preferred]

Qualifications

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]

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]

Skills

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