The Social Work Case Manager in Care Management is a professional clinician that utilizes principles of care coordination to support patients and their families/caregivers. The incumbent collaborates with the interdisciplinary team of providers, clinicians, health plans, and external partners while advocating for patients and families/caregivers to coordinate care across the continuum. The incumbent is an integral member of the Care Management team that works to improve the quality of care, patient experience, and the health of populations and individuals by focusing on the social determinants of health impacting wellness. Essential responsibilities include contributing to and/or completing initial and ongoing comprehensive assessment, providing interventions and implementing recommendations after engaging patients and their caregivers/families, focusing on the individual's risk related to social determinants of health to assure successful coordination of care across the continuum (30%). Collaborating to provide the safest transition plan for assigned patients (Inpatient/Observation/ED) to ensure timely discharge and appropriate connection with post-discharge care providers and community-based resources (25%). Educating patient, family/caregiver and physician regarding the most appropriate level of care post discharge and how to access community support, advocating for the patient, family/caregiver through effective communication with interdisciplinary team members, payers and post-acute partners to assure the safest transition (20%). Serving as a resource to provide counseling and intervention related to treatment decisions and end-of-life issues, driving collaborative conversations to establish goals of care, providing crisis interventions in cases involving Child Abuse and Neglect, Domestic Violence, Adult and Older Adult Abuse, Institutional Abuse Sexual Assault, Mental Health Disorders, Substance Use Disorders, and Identification of a Surrogate Decision Maker/Guardianship (15%). Promoting individual professional growth and development through certification, mentoring/precepting, and/or participation on department/hospital/system committees (5%). Supporting department-based goals that contribute to the success of the organization (5%). Other duties as assigned. Qualifications include a Master's degree in Social Work (to be obtained within 6 months of hire), experience in a hospital or health care setting, and LSW required within 1 year of hire (with specific deadlines for incumbents). The job adheres to ethical and legal standards, HIPAA compliance, and company policies including non-discrimination and affirmative action.
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