Inpatient Social Worker Care Manager

3 weeks ago

Bethlehem, Pennsylvania, United States St. Luke's University Health Network Full time
Job Summary:

St. Luke's University Health Network is committed to delivering exceptional patient care and improving access to healthcare services. We are seeking a skilled Care Manager to join our team and play a critical role in coordinating the discharge planning needs of patients.

As a Care Manager, you will work closely with patients, families, and healthcare teams to design and implement effective discharge plans that meet the unique needs of each individual. Your expertise will help ensure a smooth transition from hospital to home or other care settings, minimizing the risk of readmissions and improving patient outcomes.

Key Responsibilities:
  • Develop and implement discharge plans that address the psycho-social needs of patients.
  • Collaborate with patients, families, and healthcare teams to design and implement discharge plans.
  • Work with multidisciplinary teams to facilitate communication and coordination of care.
  • Identify and mitigate issues and barriers to care, ensuring a successful discharge plan.
  • Monitor and update discharge plans as needed, ensuring timely and effective transitions.
  • Proactively consider options for post-acute care, including palliative care, homecare, and other services.
  • Issue applicable state and federal regulatory notices, as required.
  • Monitor risk assessment and implement discharge interventions accordingly.
  • Actively address and monitor resource utilization, documenting delays as necessary.
  • Identify patients with unplanned readmissions and complete root cause analysis.
  • Coordinate utilization of patient and community resources to facilitate effective discharge plans.
  • Collaborate with outpatient care managers to identify patients for handover and post-discharge follow-up.
  • Provide supportive counseling and advocacy to patients and families, facilitating adjustment to illness, hospitalization, and alternative care placement.
  • Facilitate resolution of issues surrounding patient care in a compassionate manner, utilizing team meetings as necessary.
  • Act as a resource to staff for regulatory issues regarding discharge planning and psychosocial processes.
  • Utilize electronic systems to accurately document care manager functions.
Requirements:

Education: MSW or equivalent from an accredited school of social work. Current NJ SW license if working at St. Luke's Warren Campus. May hire per diem BSW's currently in school within 6 months of completing MSW. If primary coverage area is OB, membership in the National Organization of Perinatal Social Workers is required.

Training and Experience: Preference is for at least two years of experience as a Social Worker in an acute hospital setting. Strong critical thinking skills. Ability to maintain collaborative and effective working relationships. Able to assert needs to patients, families, physicians, and other members of the interdisciplinary team while maintaining established rapport and relationships. Knowledge of medical terminology required. Ability to communicate both verbally and in written forms. Basic computer skills required.

Work Environment: Sitting for one to two hours at a time, walk on all surfaces for up to five hours a day, and climb stairs. Must be capable of driving a car and have the ability to finger and handle objects frequently. Occasionally firmly grasp, twist, and turn objects with hands and fingers. May be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Staff must have the ability to hear as it relates to normal conversations and high and low frequencies and to touch as related to telephone and computer keyboard.

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