Social Worker Case Manager II

About the role

The Social Worker Case Manager II is a key member of the Care Management team, responsible for coordinating patient care across the continuum, integrating clinical social work expertise with knowledge of post-acute care needs, behavioral health, and community resources to ensure safe, timely, and cost-effective transitions of care.

Responsibilities

• Demonstrates the knowledge base and essential skills required to effectively carry out the job, including interpreting, analyzing, and applying relevant psychosocial and clinical data to prioritize and determine a course of action.
• Effectively communicates and collaborates with culturally and professionally appropriate interpersonal skills, and demonstrates effective time management and initiative to carry out job responsibilities in a timely manner.
• Assesses, plans, implements, and evaluates strategies that ensure the appropriate utilization of community and psychosocial resources and management of length of stay.
• Creates and implements a discharge plan for every admitted patient, assessing each patient’s psychosocial, functional, legal/financial, and safety status, and develops a discharge plan tailored to the patient’s needs and problems.
• Collaborates with physicians, nurses, and other ancillary staff, multidisciplinary team members, and community resources to make recommendations for effective, appropriate patient management.
• Identifies and addresses patients’ and families’ needs related to social determinants of health (SDOH), and refers to appropriate resources such as community agencies, private caregivers, behavioral health and psychosocial services, transportation assistance, medical and housing support, and educational materials.
• Monitors patient length of stay and utilization of resources on an ongoing basis, identifies avoidable days and opportunities for process improvement, and recommends actions to optimize efficiency and resource use.
• Participates in clinical performance improvement activities as needed and as assigned, and completes readmission interviews with patients/families to help determine psychosocial causes of readmission.

Qualifications

• Master of Social Work required.
• Minimum of two (2) years of clinical social work experience with one (1) year of Case Management experience required in acute or post-acute setting such as acute care hospital, post-acute rehabilitation, home health or community nursing setting.
• Must have active CPR certification and follow hospital policy for renewals.
• Case Management Certification (ACMA or CCM) required within two (2) years of hire.

Skills

The ability to demonstrate effective customer service behaviors as defined by the organization’s mission, vision, and values, and to work within the CMSA Standards of Practice and adhere to the NASW Code of Ethics.