MSW / RN Case Manager – Full time

About the role

The MSW/RN Case Manager position is responsible for consultation and direction of Social Services for all operations of the facility. They assist patients in arranging financial resources from Medicare/Medicaid and other programs, serve as a resource individual for the hospital, Home Care, Nursing home, Physicians and patients, and assist in various psycho-social functions based upon the age of the individual served.

Responsibilities

• Assesses the patient and caregiver psychosocial status, the caregiver’s ability to function adequately, and the environmental resources and obstacles to maintaining safety.
• Assesses the patient’s potential risk of suicide and/or the potential for abuse.
• Assesses special needs related to cultural diversity including communication, space, role of family members, and special traditions.
• Provides social services including short-term individual counseling, crisis intervention, providing information on preparation of Advance Directives, funeral planning, and issues involving transfer of fiscal, legal, and health care responsibilities.
• Accurately documents care in clinical and progress notes.
• Identifies family dynamics, communication patterns, and involves caregivers in the Plan of Care.
• Identifies and utilizes appropriate community resources and assesses the patient’s caregiver’s ability to access them.
• Evaluates the patient and family response to psychosocial interventions. Addresses patient and family questions.
• Evaluates the need for long-term care when appropriate and assessing ability to accept change in level of care.
• Assists the family in assessing the financial resources when appropriate.
• Evaluates patient and family response to intervention when referred to community agency and satisfaction with services provided.
• Communicates psychosocial information to the inpatient facility when the level of care changes.
• Participates in in-service programs, quality improvement activities, and Hospice Professional Advisory Board as requested.
• Maintains confidentiality and supports patient and family rights and responsibilities.
• Ensures patient needs are met in compliance with applicable regulations, policies, and procedures.
• Develops, implements, and maintains partnerships with other community providers and resources, collaborating and/or referring as necessary to evaluate mental or physical conditions and ensure service efficacy.
• Treats all patients and their families with respect and dignity. Identifies and addresses psycho-social, cultural, ethnic, and religious/spiritual needs of patients and families.
• Compiles and documents information concerning patient physical and mental condition and assists in discharge planning which provides the necessary post-hospital care based upon the needs of the patient.
• Contacts outside agencies for patients/residents and/or family members when patient is ready to be discharged, but cannot remain alone.
• Works with patients and family concerning financial planning, application for financial aid, placement adjustment, and Medicare, as needed.
• Maintains active list for nursing home placements. Completes proper forms and procedures for patients placed on nursing home lists.
• Completes Swing-Bed documentation including Medicare Part A denial letters.
• Prior to or upon admission to the Swing Bed program, obtains insurance information available (including drug coverage) and provides information to Pharmacy and Billing Departments for coverage verification and billing purposes.
• Upon admission to the Swing Bed program, reviews admission packet with resident and/or designee to obtain appropriate signatures and distribution of forms.
• Interacts professionally with patient’s family and involves the patient/family in the formation of the plan of care.
• Participates in Interdisciplinary Care Plan conference and is an active member of the Interdisciplinary team.
• Completes Medicare Level of Care Screening for applicable patients.
• Refers patients who require ongoing counseling or other services to appropriate agencies.
• Documents in medical records each contact made with or for patients. Keeps physician informed of progress with their patients.
• Maintains updated Policy and Procedures for the Social Services Department.
• Assists in locating resources for individuals requiring special services or durable medical equipment.
• Is responsible for planning, directing, and carrying out the activities program. Uses community resources in an assertive fashion to facilitate an ongoing program. Planned activities will include physical, social, and educational programs.
• Maintains a monthly activities calendar.
• Assists patients to set up and access patient portal.

Qualifications

• A minimum of a Master’s Degree of Social Work (MSW) from a school or a school of Social Work accredited by the Council on Social Work Education preferred. Must possess and maintain a valid license from the State and Michigan.
• Previous hospital, hospice, and long-term care facility experience preferred.
• Knowledge in Federal and State rules and regulations and Medicare guidelines. Knowledgeable in insurance, people, social work theory, and resources available in the community.
• Excellent written and oral communication skills.
• The ability to deal with people who are in a variety of emotional states. Individual and group discussion skills. Knowledge of principles and processes for providing customer and personal services.
• Critical Incident Stress (CISM) debriefing for traumatic incidents with staff, management, and patients preferred.
• Knowledgeable in medical terminology and able to work with other staff.
• Work experience in gerontology or related area preferred.
• Must have current and maintain valid driver’s license and vehicle insurance.
• Demonstrated ability to provide a supportive and sensitive approach to patient and family needs.
• Must demonstrate the ability to deal effectively with stress, flexible schedule demands, and evening hours.
• Must demonstrate a daily commitment to the Standards of Behavior and Core Values of BCMH.