Social Woker

Job Summary:

Responsible for the functions of case management, utilization review, discharge planning and transition of care.

ESSENTIAL FUNCTIONS:

• Responsible for establishing and maintaining open, effective communication between the facility and alternate level health care organizations, patients and their families, physicians, and third party payers.
• Acts as a patient advocate to hospital clients.
• Determines medical necessity for admission and continued stay as well as patient status through appropriate application of nationally recognized criteria.
• Provides clinically based case management, discharge planning and care coordination to facilitate the delivery of cost effective quality healthcare.
• Provides patient/ family with information about home health care, skilled nursing facilities, rehabilitation facilities and appropriate providers. Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered.
• Maintains active communication with members of the multidisciplinary care team to affect timely and appropriate patient care and facilitate discharge.
• The case manager/social worker is on site and available seven days a week, as well as holidays and therefore is required to work a weekend rotation an occasional holiday and required to be on-call.

ADDITIONAL RESPONSIBILITIES: As assigned.

MINIMUM POSITION EDUCATION/QUALIFICATIONS:

• Education -Graduate from an accredited school of Social Work preferred. Or Bachelors degree in healthcare related field..
• Work Experience - Five years clinical experience in an acute care setting is strongly preferred.
• Training - Basic Computer
• License/Certification - Current New Mexico License as a Social Worker (LMSW)

KNOWLEDGE/SKILL/ABILITIES:

• Maintains knowledge and understanding of Medicare and Medicaid guidelines and regulations pertaining to utilization review, discharge planning and Long Term Care (or transitional care).
• Experience in the use of InterQual or Milliman criteria and review processes preferred.
• Demonstrates the willingness to research, learn, and obtain knowledge for the performance of the position.
• Knowledge in the areas of Case Management and Utilization Management, experience with managed care as it relates to third party payers preferred.

POSITION RESPONSIBILITIES:

• Directs, coordinates and provides Case Management to patients in caseload.
  • Assess patients to identify needs, issues, resource and care goals.
  • Completes Case Management assessment, reviews admitting diagnoses/problems, determines a plan to address patient's needs and optional/preferred level of care.
  • Identifies potential transition planning problems in a timely manner to set up services required.
  • Works with the attending physician and care team members to move patient through the hospital system and set up appropriate services or referrals. Works collaboratively to develop a discharge plan early in hospitalization.
  • Proactively affects the system to facilitate efficient flow of care.

• Reviews patient admissions to determine the medical necessity for admission and continued stay using pre-established criteria.
  • Identifies cases that fail criteria and refers them to the physician advisor appropriately.
  • Assists and educates physicians on appropriate documentation warranting acute hospitalization.
  • Acts as a resource when issuing notices of non-coverage (Medicare HINNs), Condition Code 44, or the 2 Midnight Rule to both the physicians involved and the patients. Explains UR processes and insurance coverage requirements.
  • Consults with physicians and their offices and payers, to determine the appropriate status of a patient.
  • Actively monitors observation status patients and seeks clarification of the status by the 24 hour mark and no later than 48 hours.
  • Provides clinical data/information to contracted third-party payers while the patient is hospitalized to ensure continued reimbursement and avoid delays in reimbursement with in the established timeframe set by the contracts.

• Completes or oversees the completion of the Case Management Assessment of patients and support systems to facilitate the most appropriate and timely transition plan.
  • The completion of the Choice Form for Medicare.
  • Administering of the Important Message for Medicare.
  • The completion of assembling the necessary referral paperwork prior to discharge.
  • Documents offering of choice for SNF, DME or Hospice referrals according to Medicare requirements.
  • Communicates the discharge plan to patients/their representatives and pertinent healthcare team members.

• Interacts, communicates and intervenes with the multidisciplinary healthcare team in a purposeful goal-directed fashion. Works proactively to maximize the effectiveness of resource utilization. Anticipates and facilitates problem resolution around issues of resource used and continued hospitalization and discharge planning.
  • Maintains a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
  • Utilizes appropriate resources in cases that present ethical dilemmas.
  • Explores strategies to reduce LOS and resource consumption.
  • Participates in daily rounds.
  • Refers to the PA those cases in which appropriate resource utilization is to be evaluated.
  • Reviews physician documentation and when needed seeks clarification relative to diagnosis and the patient's clinical state.

AGE-RELATED COMPETENCIES: Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position. Knowledge of pediatrics to geriatrics is necessary.

Information Management: Treats all information and data within the scope of the position with appropriate confidentiality and security.

Risk Management/Quality Management/Safety: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.

ENVIROMENTAL CONDITIONS: Work environment consists of daily patient contact, which may include exposure to blood, or other body fluids.

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