Social Worker - Case Manager - FT - Days MSW / LMSW

About the role

The Case Management Social Worker provides medical social work services to patients in the hospital setting. They assess social, psychological, cultural, environmental, and financial situations, collaborate with healthcare teams, and develop and implement plans to address identified needs.

Responsibilities

• Assesses the social, psychological, cultural, environmental, and financial situation of each referred patient.
• Collaborates with RN Case Manager, patients, families, healthcare team members, and community agencies to develop and implement plans to address identified needs.
• Evaluates the effectiveness of plans and initiates change as needed.
• Uses crisis intervention, problem-solving model, community organization, and advocacy skills in identifying needs and resources in the hospital and community.
• Provides cross coverage for all Social Workers as required across all settings in the care continuum, including weekend rotation (as needed).
• Uses a family systems theory framework to gather information.
• Identifies legal, financial, social, educational, and environmental factors affecting medical care and/or discharge plans.
• Informs team members of critical information that affects patient's stay while in the hospital and/or discharge plan.
• Assesses and assures appropriate reporting of potential/actual abusive relationships, such as child/adult abuse, neglect, or domestic violence.
• Assesses and initiates or assists in arranging appropriate interventions and referrals for psychiatric/substance abuse disorders upon discharge.
• Expedites the discharge plan through excellent networking and team skills within the patient's expected length of stay per working DRG.
• Provides patient advocacy and ensures patient's Freedom of Choice and Medicare's Important Message.
• Attends multidisciplinary rounds to ensure timely communication with the team.
• Receives referrals for appropriate placement (NH, SNF, Assisted Living, LTAC, Acute Rehab etc.) from Case Manager or Care Coordinator.
• Reviews patient information from the electronic record, interviews patient and/or family for preference of facilities, secures signatures on Freedom of Choice form, completes DMA 6 where required, and obtains appropriate signatures.
• Updates any changes in insurance, demographic information, patient level of care, etc. Ensures appropriate discharge documentation is available to accompany patient to the facility.
• Stays in touch with the team, patient, and family regarding post-acute plans. Coordinates appropriate transportation.
• Affords assistance with the application process for indigent medications, working specifically with indigent programs and pharmacy assistance programs.
• Affords assistance to patients/families with the process to ensure community resources are obtained for discharge to lower level of care, to include homeless resources. Continuously seeks new community resources and keeps team informed.
• Provides therapeutic support for patients and families by listening to verbal communications and observing non-verbal behaviors. Assists patient and family in understanding medical plan of care and discharge plan. Facilitates support groups as needed.
• Supports patients and families in difficult discharge placements and for immigrants that require placement outside the USA.
• Encourages participation in community-based committees and hospital committees as related to post-acute care services. Encourages participation in system-wide service projects.
• Facilitates support groups as requested.
• Responds to calls/referrals/consults within 24 hours. Communicates in a respectful manner. Responds to calls with appropriate resources or manages the call in a satisfactory manner. Contacts supervisor and other resources for assistance when needed.
• Completes all documentation related to actions taken.
• Works all scheduled shifts, including weekend rotation, remote coverage, and on-call schedule.

Qualifications

• Licensure or other certifications: Masters Degree in Social Work from an accredited School of Social Work; CCM (Case Management Certification) or ACM (American Case Management Certification) preferred.
• Experience: One (1) year experience in a hospital preferred, agency or institution providing related health care services.
• Knowledge: Knowledge of state and federal programs that provide medical care and financial support to individuals, knowledge of community resources, ability to work with diverse patient and staff populations, ability to work independently and amicably in group situations, conversant with current thinking on professional conduct and practice, strong clinical assessment, intervention, and counseling skills across all age ranges, knowledge of Long Term Care regulations, financial eligibility and admission criteria, knowledge of adoption and surrogacy policies and regulations, ability to think 'outside of the box', and consistent creation of new, and effective solutions to today's problems and opportunities.
• Skills: Excellent communication skills, exhibits a positive attitude, social work assessment and counseling skills, ability to work with individuals of varying cultural and socio-economic backgrounds.