SW-Hospital Case Manager LMSW, PRN - Pediatrics

Inspire health. Serve with compassion. Be the difference.

About the role

Provides screening, assessment, planning, problem resolution, resource management, counseling and crisis management as they relate to the health care and discharge planning needs of the patient/family. Manages and collaborates in discharge planning for patients with simple and complex needs and coordinates with agencies providing post hospital care. Functions as an interdisciplinary health care team member collaborating with other health care professionals to coordinate in the assessment of patient/family needs and development of a comprehensive plan of care, and to coordinate and facilitate resolution of patient needs. Services are provided in accordance with accepted standards of professional practice and the policies and procedures of Prisma Health.

Responsibilities

• On the basis of preliminary risk screening, assesses patients’ and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.
• Documentation in the medical record is legible and conforms to hospital department policies and procedures including but not limited to screening, initial discharge plan, change of condition updates and final discharge plan.
• Promotes the Hospital Case Management team concept with discharge planning activities as requested and/or assessed.
• Maintains close communication with post-acute care providers.
• Accountable for readmission assessments, risk stratification review and action planning.
• Uses proactive measures towards comprehensive discharge planning.
• Screens and coordinates all SNF and Rehab facility referrals as deemed appropriate.
• Provides consultation to team members regarding clinical needs as deemed appropriate.
• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system.
• Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs.
• Provides intervention in cases involving child