Social Work Care Manager PRN

Schedule

• Shift: PRN
• Location: United States of America

About the Role

Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate.

Responsibilities

• 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.
• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.
• 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

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

Qualifications

• N/A

Skills

• N/A

Benefits

• N/A

Pay

• $26.89 - $50.01

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.

Physical Requirements

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