Social Work Case Manager

About the role

In support of patient progression practice, create optimal outcomes for the patient and the family by managing complex psychosocial and economic barriers to patient progression. Through advanced practice skills, mobilize resources to reduce risk to the patient and families secondary to social determinant–based needs and challenges. Provide patient support with cultural humility to ensure that interventions by the care team are rendered respectfully to diverse populations.

Responsibilities

• Identify patients and/or families requiring coordination of continuing care or community support members of the care team.
• Review medical records, attend rounds, and respond to patient needs.
• Apply knowledge based on professional experience and adhere to practice standards consistent with patient progression and the strategic plan.
• Work collaboratively with the RN Case Manager and the treatment team to develop and coordinate a safe, timely, and appropriate discharge plan across the care continuum, addressing psychosocial barriers and multiple resource-dependent levels of care that comply with regulations and laws regarding patient/family participation and choice.
• Coordinate post-acute discharges for complex patients in collaboration with Care Management Discharge Manager.
• Identify the need for and conduct, in a timely fashion, patient-family meetings that result in decisions regarding advance directives, comfort measures, power of attorney, guardianship, conservatorship, and goals of care.
• Complete initial psychosocial screen of patients and families as indicated.
• Serve as the lead in addressing psychosocial needs related to social determinants of health, barriers to equal access to healthcare, and patient progression; this includes obtaining charity and financial resources, legal guardianship, adoptions, psychiatric referrals, and competency determination.
• Provide referrals for post-acute transitions to/for LTACH, SNF, IRF, LTC, HH, and DME.
• Conduct practice consistent with social work ethical principles, adhering to standards set forth by NASW and ACMA Case Management practice standards.
• Identify the need for and conduct family meetings that result in comfort, treatment, and discharge planning decisions and other important outcomes.
• Lead Care Coordination/Interdisciplinary Rounds and document accordingly.
• Advocate for patient care and timely discharge plans.
• Work with people and agencies in the community to improve responsiveness, capabilities, alignment, and evaluation of services to patients and families.
• Utilize age-appropriate assessments and interventions during all client contacts.
• Collaborate with Risk Management, Patient Relations, Utilization Management, the Ethics Committee, and other departments for ethical issues and utilize the NASW Code of Ethics in appropriate decision-making.
• Demonstrate flexibility and partnership with the care management team members to ensure patient needs are met.
• Assist patients and families in understanding their illness and treatment options, consequences of various treatments or refusal of treatment, and necessary levels of care, including acute, subacute, and community services.
• Assist patients and families in communicating with the treatment team.
• Educate hospital staff on patient psychosocial needs.

Qualifications

• Master’s degree in Social Work from a CSWE-accredited program required.
• Expectation to become a Licensed Clinical Social Worker (LCSW) per departmental guidelines.

Preferred qualifications

• MSW or, optimally, LMSW/LCSW.
• At least one year of experience performing discharge planning in an acute or subacute setting.
• Documented success as a Medical Social Worker.

Physical demands

Job requires sitting for prolonged periods, standing/traveling or use of assistive devices and climbing (stairs, steps). Proficient communicative, auditory, and visual skills; attention to detail; ability to hear, speak, see, distinguish colors, read, and write legibly; ability to lift/push/pull less than 20 lbs. May be exposed to chemicals, blood/body fluids, and infectious disease.

Pay

The pay range for this role is $57,907.20 – $92,643.20 annually. Individual compensation will be determined by the selected candidate’s qualifications, previous work experience, and/or education.

Benefits

• Medical, dental, and vision insurance.
• Paid time off; long-term and short-term disability; retirement savings; health savings plans; and flexible spending accounts.
• Certification and education support.
• Generous paid time off.