Transitional Care MSW Case Manager II - Continuum of Care

About the role

The role involves collaborating with various healthcare teams to manage patient care transitions, focusing on proactive care planning and interventions.

Responsibilities

• Identifies care management patients by accessing Emergency Department (ED) or inpatient services and establishes personal contact within 24 hours of referral.
• Creates and coordinates a focused transitional and discharge plan of care for chronic, high-risk patients based on initial assessment.
• Conducts concurrent medical record review to measure patient progress against goals established for discharge.
• Prepares and presents cases for discussion at scheduled meetings.
• Expedites proper sequencing and scheduling of interventions, treatments, and procedures in accordance with the patient's need during inpatient care.
• Manages continuity of effective and timely communication between patient and providers.
• Communicates patient needs with anticipated site coordinator as necessary.
• Reviews transition/discharge plan to ensure the patient and his/her family understand the plan including medications and discharge needs.
• Captures and communicates any problems or issues that affect patient flow, patient satisfaction, patient safety, length of stay management, or outcomes to the department manager and/or appropriate key stakeholders.
• Works with acute and primary care multi-disciplinary care team to prevent readmissions; identifies and communicates relevant information and facilitates care conference(s) as necessary.
• Displays innovation in problem solving and critical thinking.
• Assists leadership in Transitional Care Program development and continuous improvement through measurement and feedback of appropriate outcome based processes and strategies.
• Actively participates in developing program structure, tools, procedures and communication strategies.
• Recommends changes for process improvement in program policies and operations to meet objectives.

Qualifications

• A Master’s Degree in Social Work.
• Non-supervisory – Two (2) years of experience in social work.
• Current Basic Life Support (BLS) card.

Skills

• Knowledge of Alaska Tribal Health System, ANTHC, and Alaska Native culture(s) and politics.
• Knowledge of multiple care environments – Inpatient (IP), Outpatient (OP), Emergency Department (ED), Skilled Nursing Facility (SNF), and Home.
• Knowledge of the healthcare system and its component parts including sites of care, delivery models, and the roles of various providers and health care professionals.
• Knowledge of the community-based social service delivery system and its interaction with the health care system.
• Knowledge of working with multi-cultural populations.
• Assesses and prioritizes multiple tasks, projects, and demands in a high stress environment.
• Manages patient complexity and multiple patients with diverse needs.
• Works on teams to plan and produce defined outcomes within given timelines.
• Constantly assesses and anticipates the needs of the patient and his/her environment.
• Establishes and maintains effective professional working relations with co-workers, providers, and representatives of other health care organizations.
• Collaborates and facilitates relationships and consensus among the patient, family, and multidisciplinary providers from many different disciplines.