Social Worker - Care Coordinator TMC Rincon

About the role

Partners with a multi-disciplinary team to coordinate a plan of care utilizing expertise in counseling, crisis intervention, and medical-legal issues to ensure optimization of health outcomes for patients and their families.

Responsibilities

• Collaborates and communicates with multidisciplinary teams in all phases of discharge planning, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation to assess, document, and address psychosocial, cultural, emotional, and economic needs of patients and families during hospitalization and discharge planning.
• Assesses, creates, implements, evaluates, and modifies timely discharge plans.
• Assesses, intervenes, and acts as a resource in medical-legal situations for patients and families.
• Requests assistance from RN Case Manager to enter nursing orders to ensure assigned patient caseload discharge planning and transitional care needs are met.
• Assists patients and families in making difficult decisions while honoring their preferences and values to move the discharge plan forward.
• Collaborates with patients, family/caregiver, nursing, physician(s), and other multidisciplinary team members to create consensus around discharge planning issues.
• Ensures documentation in the electronic medical record is timely, clear, complete, concise, and organized.
• Monitors clinically high-risk and complicated cases and institutes necessary actions to promote quality care with timely escalation as appropriate.
• Acknowledges and completes case management consults in a timely manner and identifies patients meeting criteria for case management.
• Coordinates cases between healthcare providers and payors.
• Facilitates precertification and payor authorization processes for medication.
• Facilitates collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and transition of care.
• Facilitates coordination between the multidisciplinary team and patient/family/caregiver for care conferences when indicated.
• Develops treatment plans and discusses proposed courses of treatment with the patient’s attending physician, patient, family/caregiver, and other multidisciplinary team members.
• Ensures patient/family/caregiver/staff concerns are appropriately resolved in a timely manner.
• Identifies populations and patients at risk for readmissions, establishes goals with patients and families, coordinates specific focused discharge interventions and services, and makes contact with community partners for continuity of care.
• Works with clients and the multidisciplinary team to identify discrepancies and barriers to health, wellness, and independence toward health equity.
• Improves understanding of access points for medical care to decrease use of emergency resources, hospital admissions, readmissions, and unnecessary expenditures.
• Analyzes current operations, policies, systems, and procedures, and develops and implements necessary and innovative changes.
• Exhibits excellence in customer service through appropriate attitude and interaction with all patients, visitors, and staff.
• Adheres to and supports team members in exhibiting organizational values of integrity, community, compassion, and dedication.
• Assists with program planning, development, and evaluation.
• Adheres to organizational and department-specific safety, confidentiality, values, policies, and standards.
• Collaborates with the multidisciplinary team, outpatient care team, and community partners to assist with length of stay, patient throughput initiatives, and creatively resolve issues preventing safe and timely discharges.
• Ensures all critical elements of the plan of care are communicated to the patient/family and healthcare team and documented to assure continuity of care.
• Performs related duties as assigned.

Requirements

• Master's in Social Work (MSW) or equivalent (Master of Science in Social Administration (MSSA)).
• One (1) year of related social work experience.
• HeartSaver First Aid CPR Certification or Basic Life Support (BLS) Certification.

Skills

• Knowledge of crisis intervention skills and techniques, psychosocial factors influencing behavior, counseling concepts, and discharge planning.
• Knowledge of direct patient care and critical care procedures and techniques, tools, and responses required to ensure optimal patient care.
• Skill in evaluating cases and determining appropriate care and status.
• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and collaborate with case management leadership on creating and updating necessary standards of work.
• Ability to effectively present information and respond to inquiries or complaints from employees, patients, and/or their representatives, and the general public.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Ability to interpret specific instructions displayed within a flowchart or diagram format.
• Initiates and facilitates referrals through community partners to complete appropriate transition of care needs.
• Excellent interpersonal communication and negotiation skills.
• Strong analytical, data management, and PC skills.
• Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
• Understanding of pre-acute and post-acute venues of care and post-acute community resources.
• Strong organizational and time management skills, with the capacity to prioritize multiple tasks and role components.
• Ability to work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families.
• Performs duties to promote quality patient care and customer service/satisfaction while ensuring safety, cost efficiency, and a commitment to continuous quality improvement (CQI).
• Ensures safe care to patients by adhering to policies, procedures, and standards within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency, supporting department-based goals contributing to organizational success; serves as preceptor, mentor, and resource to less experienced staff.