Career Center

Job Summary

The Licensed Social Worker will provide psychosocial assessments for patients and families related to hospitalization, and coordination of care and discharge planning with the interdisciplinary team, patients and families and the community.

Working Environment

• May be exposed to dust/particulate matter.
• May be exposed to limited hazardous substances or body fluids, or infectious organisms.
• May be exposed to toxic, caustic, chemicals, and / or detergents.
• May be scheduled as needed, including overtime.
• Organizational Expectations
• Adheres to and exhibits our core values: Reverence: Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us. Integrity: Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness. Compassion: Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community. Excellence: Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
• Attends staff meetings and completes mandatory in-services, requirements and competency evaluations on time.
• Compliance: Understands regulatory requirements with regard to compliance and all other laws and regulations that apply to the organizational operations (e.g. Code of Conduct) and how these regulations apply to the individual's role/ department/ unit. Proactive in addressing compliance issues; reporting through appropriate channels such as supervisor, chain of command and Ethics Point. Completes mandatory introductory and ongoing training within the specified timeframes.
• Maintains current knowledge in present areas of responsibility (i.e., self-education, attends ongoing educational programs).
• Works collaboratively and supports efforts of team members. Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.

Job Roles

CARE MANAGER-SOCIALWORKER Principal Responsibilities and Tasks

PATIENT CARE:

• Screen, identify and provide psycho-social assessment to patients and family members/significant others. Formulate, develop and implement a comprehensive discharge plan. Provide education to patients and families around issues related to adaptation to the patient's diagnosis, illness, treatment, life/social situation, end of life/palliative care/hospice. Advocate for patients and families throughout the continuum of care for procurement of services and optimal health. Coordinate agency involvement in the patient's care both in the inpatient and outpatient settings. Demonstrate an understanding and knowledge of counseling interventions. Applies knowledge of age-specific, cultural, psycho-social and developmental issues during assessment, documentation and interventions with patients/families.

COLLABORATION AND COORDINATION OF CARE:

Maintains active communication with physicians, the health care team, billing, payers to effect appropriate management through the continuum of care recommending alternatives to the care and discharge plan based upon available resources and patient/family choice. Negotiate with payers and community resources to create best options for patients/families. Utilizes problem solving skills to resolve conflicts and optimize alternatives for patients and families. Establishes collaborative relationships with co-workers, health care team, agencies, vendors and payers on behalf of patients. Maintain a working knowledge of relevant medical/legal issues that impact on patient care, e.g., adult and child abuse, guardianship -

RESOURCE UTILIZATION:

• Maintain working knowledge of and liaison with community agencies and resources.
• Understand and educate the team and patients/families regarding medical necessity and appropriate level of care. Actively engages members of the healthcare team in discussions regarding care and discharge plan and timely progression through the hospitalization through interdisciplinary rounds, face to face and telephone communication and follows up to ensure that interventions are implemented according to plans. Practices early identification of risk and needs and referrals, providing a minimum of 3 referrals for placements initially with ongoing additional referrals as needed to insure timely discharge. Provides alternate discharge plans early on when disposition is unclear to ensure timely discharge to appropriate level of care.
• Multi tasks, works independently with minimal supervision, and develops unique solutions to complex discharge barriers(thinks outside of the box).

COMPLIANCE:

• Honors and documents provision of patient choice.
• Monitors patient status/level of care and issues and educates about observation notifications within established guidelines.
• Provides and educates regarding the second Important Message for Medicare within established guidelines. Reports suspected abuse/neglect of children and vulnerable adults.
• Maintains strict standards of confidentiality as defined by organization policy, and federal and state regulation.

PROFESSIONAL GROWTH:

• Exercises independent judgment and discretion based on case management principles that lead to reduced length of stay, denial avoidance, and appropriate utilization avoidance.
• Takes ownership of learning needs and updated knowledge of regulation and best practices.
• Searches for resources and resolutions that improve efficiency and productivity. Demonstrates pursuit of resolution of difficult situations rather than distress.
• Seeks involvement in professional organizations specific to hospital and transitional case management.