RN/SW Case 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. Assesses patients’ and families’ wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning. Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan. Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs. Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.

Responsibilities

• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Provides patient and family advocacy, and support patient’s choice and patient rights during hospitalization.
• Communicates with Payors patient’s needs for authorization for post-acute care as needed.
• Assesses readmitted patients for the patient’s and family’s perceived reasons for the readmission.

Requirements

Knowledge, Skills, And Abilities:

• 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

Qualifications

• Master's [Required]
• 2+ care management experience [Preferred]
• 2+ social work [Required]

Skills

• Accredited Case Manager (ACM) [Preferred]
• Certified Case Manager (CCM) [Preferred]

Benefits

All the benefits and perks you need for you and your family:

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Schedule

Schedule Full time Shift Day (United States of America)

Pay

Pay Range $24.47 - $62.59

Additional Information

Additional Licensure or certification requirements may apply depending on the specific unit or state in which this position is located. Please consult the relevant credential grid for detailed information regarding these requirements