Medical Social Worker Case Manager

Responsibilities

• Provides social work services to patients, families, and individuals including psychosocial assessment, screening, determination of needs evaluation, appropriate interventions and follow-up, and discharge planning.
• Implements interventions substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources and payer network.
• Participates as part of 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 and initiates/coordinates interventions with other members of the health care team.
• Maintains up-to-date knowledge of community resources, legislation, and regulations impacting health care delivery and educates patients and families on these issues as appropriate.
• Provides resources to patients and families to ensure timely discharge and appropriate links 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.
• Connects patients to appropriate agencies for issues of suspected abuse and neglect, domestic violence, guardianship, and other social matters.
• Collaborates with community agencies and institutions to plan continued care and coordinate interventions.
• Provides resources and education to patients and families regarding appropriate resources and access to community social services.
• Communicates effectively with patients, family, health care team members, and community agencies to facilitate resolution of issues impacting continuity of care (e.g., prior-approvals, application requirements, transfer paperwork).
• Documents activity according to department and program protocols or standards.
• Manages the progression of patients' stay to optimize length of stay (LOS) and ensure appropriateness of assigned Level of Care.
• Manages and coordinates patient care within an ACO environment to facilitate patient outcomes through in-network care coordination and reduce unnecessary readmissions.
• Accountable for site-specific KRA goal achievement related to Care Coordination across the continuum.
• Participates in the orientation of new staff and/or education of social work students.
• Provides education to patients/families regarding Advance Directives for health care decision-making and assists with execution of these documents as appropriate.
• Participates in legal proceedings as necessary to secure legal decision-makers.
• Maintains professional standards and responsibilities for practice according to accreditation, hospital, system, state, and NASW Standards and Code of Ethics.
• Completes all required continuing education to maintain licensure and increase knowledge within area of practice specialty.

Requirements

• Master’s degree in social work from a Council on Social Work Education (CSWE) accredited school.
• 1 year of social work experience in healthcare.
• License/Registration/Certification: IL-LSW Eligible, LCSW preferred issued by the State of Illinois/WI-Social Work Certification issued by the State of Wisconsin.

Skills

• Demonstrated knowledge of social work principles and methods and the ability to apply these in a health care setting.
• Demonstrates time management, professional accountability, and documentation skills.
• Demonstrates communication skills and the ability to collaborate within a multi-disciplinary team.
• Demonstrates and acts in accordance with safety principles of an accountable care organization.

Physical Requirements and Working Conditions

• This position requires travel, therefore, will be exposed to weather and road conditions.
• Operates all equipment necessary to perform the job.
• Exposed to a normal office environment and patient care environment.
• May be exposed to hazardous materials and life-threatening diseases; must abide by personal protective equipment as ordered.
• Weekend, holiday, and evening coverage per site requirement.
• Position requires sitting, standing, speaking, reading/writing, and walking throughout the workday.
• Fast-paced work environment with established time constraints per site.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.