Social Work Case Manager MSW or LCSW, Care Coordination, Per Diem, Days, weekends required

About Marinhealth

Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch.

Job Description Summary

The Social Work (SW) Case Manager, in collaboration with members of the inter-disciplinary healthcare team, leads the development and implementation of the multidisciplinary plan of care for patients, determining appropriate patient status and level of care; ensuring effective quality and cost-efficient outcomes, and supervises the provision of the discharge plan of care. This position functions as the key linkage between the physician, staff, and hospital leadership in the day-to-day management of appropriate and efficient patient care and functions as an advisor to the physician with accountability to escalate cases to the Manager, Director, or Physician Advisor (as necessary) to ensure the provision of appropriate and effective patient care.

Job Specifications

• Education: Master's degree from an accredited school of social work or social welfare required.
• Experience: Prior work experience in a healthcare environment is required. Acute care hospital experience or recent internship strongly preferred.
• Licenses and Certifications: Licensed Clinical Social Worker (LCSW) required at hire. Basic Life Support (BLS) required within 90 days of hire. Integrative Agitation Management (IAMTAC) required within 30 days of hire. Accredited Case Manager (ACM-SW) preferred at hire. Certified Social Work Case Manager (C-SWCM) preferred at hire.

Prerequisites and Essential Functions

• Skills: Ability to read, write, and follow English verbal and written instructions, excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills. Adhere to the professional ethics, practice, and Values ad delineated by the National Association of Social Workers (NASW) Code of Ethics. Leadership skills to delegate, functionally supervise, provide direction/guidance to staff and hold others accountable. Independent workflow organization, prioritization, and responsibility. Strong clinical assessment and critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs. Strong attention to detail and accuracy. Constructive problem solving, system planning and management. Proficient computer skills including use of Electronic Health Record and other IT applications. Supervisory principles/applications. Disease processes, current treatments and their physical and psychosocial sequelae. Individual and family development over the life span. Influence of cultural and spiritual values on health care. Applicable laws, regulations, and accreditation guidelines (e.g., CMS, DHCS, The Joint Commission, EMTALA, Title 22, and DOJ). Government and private insurance benefits (e.g. Medi-Cal, Medicare, DRGs, managed care, capitation). Child, elder and dependent adult and domestic violence reporting requirements. Available health care and community resources appropriate for populations served. Inter-Qual criteria.

Duties and Responsibilities

• Care Facilitation and Coordination: Coordinates care for an assigned unit paired team model comprised of SW Case Manager, RN Case Manager, and Case Management Specialist. Works with the multi-disciplinary healthcare team to ensure the plan of care is expedited and barriers to efficient throughput are identified and corrected. Creates a plan of care that outlines the key interventions and outcomes to be achieved during the inpatient stay. Can actively lead multidisciplinary case conferences in developing comprehensive, cost-effective case management plans that span the continuum. Makes independent assessments and recommendations regarding course of action in complex situations and recommendations relevant to multi-system or special needs patients. Identifies and refers quality and risk management concerns to appropriate level for corrective action plans and trending. Proactively solicits physician’s orders for services.
• Clinical Social Work: Provides psychosocial assessments and treatment to patients and or families related to adjustment to illness and discharge planning. Demonstrates knowledge and skills necessary to provide cultural, spiritual and age specific care by obtaining specific psychosocial information and assessing relevant information needed to identify each patient’s unique treatment and discharge planning needs. Acts as patient advocate and resource regarding patient’s needs including financial considerations. Possesses clinical expertise to effectively assess, coordinate, implement and evaluate all services required to meet the needs of the patient. Provides individual, conjoint family and group therapy as appropriate to setting.
• Collaborative: Maintains effective communications with staff and attending physicians related to patient’s psychosocial and psychiatric needs. Maintains open communication and positive working relationships with all hospital departments as well as adheres to hospital chain of command. Willing to assist others and supports other hospital personnel in providing optimal patient care. Demonstrates a clear understanding and adheres to designated unit/department/program as well as overall policy and procedure. Collaborates with physicians, patients, families and treatment team members in the development of the patient’s plan of care. Assists and promotes patient/family education and ensures that the patient’s educational needs are being met. Works with public and private sectors (i.e. public guardian’s office) to ensure best treatment outcomes as well as completes necessary documents consistent with Clinical Social Worker scope of practice. Ensures proper content, application, and submission of required legal documents impacting patient care and treatment outcomes (i.e. LPS, Probate, mandated reporting). Provides clinical information for placement and referral to outside agencies consistent with HIPAA and state guidelines for special needs populations. Interprets and cites applicable laws and regulations to staff and physicians pertinent to individual patient needs. Participates in meetings and committees relevant to specific treatment area/department/program and represents MarinHealth Medical Center at relevant community meetings and committees. Provides psychosocial education and perspective to other healthcare professionals, including nursing students or any other healthcare related practice, as indicated.
• Discharge Planning: Reviews initial hospital admission and gathers additional medical, psychosocial and financial data from needs assessment, client/family, physicians, and other health care providers. Initiates discharge planning at the time of admission. Formulates a discharge plan after completing a face-to-face interview and discusses available/appropriate care options and obtaining input from the patient/family and physician, healthcare team, insurance companies, and community-based support services. Independently case finds, coordinates and implements discharge plans for all patients with psychosocial needs. Maintains and provides current information and referral services to patients, caretakers and families related to appropriate community resources and agencies. Maintains positive working relationships with community agencies. Utilizes and expands knowledge base of community resources. Initiates contact with state, county and private resources, including family, to facilitate discharge to the least restrictive level of care. Provides advocacy for clients in accessing appropriate community-based resources. Collaborates with physicians to facilitate timely resolution of situations such as client concerns, need for referrals and discharge barriers to expedite the discharge plan. Acts as a resource and content expert for the physicians regarding an optimal care plan for patients. Identifies potential problems, prevents and/or resolves variances to the case management plan. Effectively deals with resistance and conflict in working with member of the patient care team, physicians, clients, and families. Implements all aspects of the discharge plan of care, intervening in an appropriate and timely basis when difficulties arise.