Social Worker MSW / Fairfield Hospice Gen

Job Summary

The RN Case Manager provides direct service, consultation, and coordination to facilitate expected clinical outcomes for home care patients and their families. They coordinate the plan of care in accordance with attending physician's orders and agency policies, procedures, and practices. They delegate appropriate patient care responsibilities to LPNs and Home Health Aides and supervise their performance. They teach and orient LPNs, Home Health Aides, patients, and family members in the care of the patient. They are responsible for accurate, timely, and proficient clinical and reimbursement documentation.

Responsibilities

• Manages a caseload on a daily basis.
• Aids patients and families with personal, financial, and environmental problems to obtain optimum resolution/management of terminal illness, social, and health issues.
• Identifies obstacles to compliance and assists patient/family/caregiver in understanding the goals of interventions.
• Provides bereavement counseling via telephone support, home visits, and support groups.
• Coordinates transfers to inpatient facilities and communicates psychosocial information to inpatient facilities.
• Participates in the development of the total care plan with other healthcare providers, including CHN, Hospice Nurses, PT, OT, etc.
• Participates in ongoing care conferences with the Health Care Team or Hospice Interdisciplinary Team to assist IDT members in understanding the emotional and/or social factors affecting the patient/family’s end-of-life experience and to collaborate on ensuring appropriate treatment and follow-through of established plan of care.
• Identifies patient and family needs for other home health services and refers when appropriate, such as community resources, financial aid, etc.
• Organizes and prioritizes caseload needs on a daily basis to ensure that patient needs and agency productivity standards are met.
• Keeps Hospice Supervisor/Coordinator or designee informed in a timely manner regarding weekly caseload and/or patient problems so that patient care and staffing needs are consistently met.
• Prepares a variety of reports related to direct service activities.
• Prepares and keeps legible records current on a daily basis, providing all written information regarding service record, visit, and non-visit time, statistical sheets, and reports to physicians and other personnel, according to expected time frames.
• Develops written patient care goals and expected outcomes according to individualized patient care plans in collaboration with the Health Care Team or Hospice Interdisciplinary Team on an ongoing basis.
• Updates and submits written physician orders accurately, in a timely manner, according to established timeframes.
• Collects and documents necessary financial and reimbursement information for each patient and provides verbal or written communication as required, to agency personnel and other reimbursement sources.
• Obtains prior authorization for services when indicated by calling payers and requesting and/or providing verbal or written confirmation, in a timely manner within respective established timeframes.
• Completes and processes discharge records within 24 hours after last patient visit and communicates promptly with other agency personnel, in an appropriate fashion.
• Performs related social work duties in support of the Hospice Program and the agency.
• Facilitates staff support groups, bereavement support groups, or other support groups, as needed.
• Provides individual and group consultation to other agency personnel to assist other team members in understanding the social and emotional factors related to health problems.
• Provides in-service education programs for agency staff and orientation for new staff regarding the Hospice Program.
• Participates in volunteer training program and in-service education at volunteer support meetings, as needed.
• May facilitate bereavement or other support groups as needed.
• Interprets social work program of the agency to other community agencies, such as Battered Women, DCF, DSS, Department of Aging, etc.

Qualifications

• Education & Training: Graduate of a National League of Nursing accredited program with a diploma or Associate’s Degree in Nursing. Bachelor of Science Degree in Nursing preferred.
• Licenses/Certifications: Current Connecticut RN license, or eligible for RN licensure in Connecticut, or current temporary RN permit.
• Experience: Medical/Surgical experience or specialty area, if applicable, preferred. Experience in Home Health Care or Public Health Nursing preferred.
• Skills: Basic clinical nursing skills, experience in physical and psychosocial assessment, excellent verbal and written communication skills, strong organizational skills, excellent interpersonal skills, ability to deal effectively with stress, and ability to exercise independent judgment.
• Other: Valid motor vehicle operators license, reliable personal automobile during business hours, and active automobile insurance coverage in accordance with agency policy.