Senior Social Worker Case Manager

About the Role

A key member of the Care Management team, the Social Worker Case Manager II coordinates patient care across the continuum by integrating clinical social work expertise with knowledge of post-acute care needs, behavioral health, and community resources. This role ensures safe, timely, and cost-effective transitions of care through discharge planning, quality management, and resource utilization while collaborating with the multidisciplinary team to achieve optimal patient outcomes.

Responsibilities

• Interpret, analyze, and apply relevant psychosocial and clinical data to prioritize and determine a course of action appropriate to meet patients’ management needs.
• Communicate and collaborate effectively with culturally and professionally appropriate interpersonal skills.
• Manage time and initiative to carry out job responsibilities in a timely manner.
• Assess, plan, implement, and evaluate strategies for appropriate utilization of community and psychosocial resources and management of length of stay.
• Create and implement a discharge plan for every admitted patient, tailored to the patient’s psychosocial, functional, legal/financial, and safety needs, including self-care and environmental factors.
• Collaborate with physicians, nurses, ancillary staff, multidisciplinary team members, and community resources to make recommendations for effective patient management.
• Co-manage patient caseloads on a continuous basis in partnership with RN Case Managers.
• Identify and address patients’ and families’ needs related to social determinants of health (SDOH), and refer to appropriate resources such as community agencies, private caregivers, behavioral health and psychosocial services, transportation assistance, medical and housing support, and educational materials.
• Implement the discharge plan and referrals to services, resolving delays and obstacles to discharge.
• Act as a key leader and advocate in the discharge planning process.
• Monitor patient length of stay and utilization of resources, identifying avoidable days and opportunities for process improvement to optimize efficiency and resource use.
• Communicate following the chain of command regarding proper utilization of resources, psychosocial concerns, and discharge barriers.
• Provide information regarding denials/approvals and collaborate with physicians, RN Case Managers, and insurance companies to support post-acute activities.
• Communicate denials to patients, families, and physicians as needed, specific to post-acute services.
• Enter all pertinent data (discharge plan) in data collection systems on a concurrent basis as per policy/established process.
• Participate in clinical performance improvement activities as needed and assigned.
• Complete readmission interviews with patients/families to determine psychosocial causes of readmission and enter information into appropriate systems.
• Interpret and negotiate with state, local, and federal agencies to optimize patient placement in the most appropriate setting.
• Assess and align patient needs with placement options consistent with the desired level of care.
• Work within the CMSA Standards of Practice and adhere to the NASW Code of Ethics.
• Serve on committees to promote advancement of organizational and departmental operations and practices.
• Serve as a preceptor for new hires and a mentor for other Case Managers.
• Achieve proficiency in assigned job responsibilities within 90 days.

Requirements

• Master of Social Work required.
• Minimum of two (2) years of clinical social work experience with one (1) year of Case Management experience in an acute or post-acute setting such as acute care hospital, post-acute rehabilitation, home health, or community nursing setting.
• Active CPR certification; must follow hospital policy for renewals.
• Case Management Certification (ACMA or CCM) required within two (2) years of hire.

Reports to: Director Case Management