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Social Services Care Coordinator
2 months ago
Position Overview:
The Social Work Care Manager is responsible for conducting evaluations and providing interventions aimed at assisting clients and their families in overcoming social and economic challenges that impact their health and well-being. This role involves professional discharge planning services, which include assessments and coordination of post-hospital care needs, ensuring patients and their families are connected with essential resources and options for emotional, medical, and spiritual support.
Key Responsibilities:
- Conducts comprehensive triage of all patients, prioritizing those with intricate psychosocial or financial challenges, as well as placement and community service requirements within 24 hours of admission.
- Receives referrals from RN Care Managers based on identified social work triggers.
- Identifies and evaluates barriers early in the patient's stay, collaborating with the patient, family, and healthcare team to formulate a comprehensive care plan.
- Assesses the needs of patients and families for support services and community resources, providing education and referrals as necessary.
- Evaluates the risk of readmission for specific patient groups and initiates interventions to facilitate successful transitions along the care continuum.
- Coordinates and participates in family care conferences and interdisciplinary meetings, offering consultation to patients, families, and clinical staff.
- Identifies and communicates avoidable delays or variances in the established care plan to leadership.
- Recognizes patient and family preferences, needs, and strengths to enhance interdisciplinary collaboration.
- Conducts interviews with patients and significant others to assess psychosocial situations and determine points of contact within the family.
- Develops discharge plans in collaboration with patients, families, physicians, and the healthcare team.
- Manages complex cases and advocates for patients and families throughout the care and discharge planning process.
- Utilizes knowledge of insurance benefits to optimize resource utilization.
- Documents assessments, plans, interventions, and barriers in the electronic medical record (EMR) to facilitate discharge and transitions.
- Collaborates with RN Care Managers and other healthcare professionals to ensure safe and timely transitions to the next level of care.
- Partners with external agencies to ensure continuity of care and empower patients and families to make informed health decisions.
- Represents the integrated care management department in various committees and projects focused on performance outcomes.
- Performs additional related duties as required.
Qualifications:
Required:
- Licensed Master's Social Worker (LMSW) with certification obtained within one year of eligibility.
- American Case Management Certification (ACM) or the ability to obtain certification when eligible.
Preferred:
- Certification in Case Management (ACM or CCM).
- Three years of experience in acute hospital care or social work.
- Basic Life Support (BLS) certification as a Healthcare Provider.
Skills and Abilities:
- Ability to manage crisis situations calmly and effectively.
- Strong organizational skills to handle multiple tasks within tight deadlines.
- Competence in working with diverse teams and individuals.
- Proficiency in using hospital information management systems and Microsoft Office applications.
- Excellent communication and interpersonal skills to interact with various stakeholders.
