Case Manager-Social Worker Per Diem
19 hours ago
Partners with a multi-disciplinary team to coordinate a plan of care utilizing expertise in counseling, crisis intervention, and medical-legal issues to ensure optimization of health outcomes for patients and their families.
Key Responsibilities
Assesses, documents, and addresses psychosocial, cultural, emotional, and economic needs of patients and families during the hospitalization and discharge planning process.
Collaborates with the hospital care team, outpatient care team, and community agencies as needed to creatively resolve issues that could prevent safe and timely patient discharges.
Ensures documentation in the electronic medical record is clear, concise, and organized.
Assesses, intervenes, and acts as a resource in medical-legal situations for patients and families.
Identifies community resources and programs appropriate for patients and families.
Develops treatment plans and discusses proposed course of treatment with patient's primary physician.
Provides follow-up on open issues to ensure patient/family/staff concerns are appropriately resolved in a timely manner.
Additional Responsibilities
Assists patients and families in making difficult decisions while honoring their preferences and values to move the discharge plan forward.
Evaluates case management processes to initiate changes when indicated to ensure efficiency and maximize benefit to patient and organization.
Intervenes as needed in emotional crisis situations with patients and families.
Performs related duties as assigned.
Specialized Responsibilities
Coordinates plan of care in a clinic setting.
Provides assistance as needed to in-patient case management team to ensure timely follow-up appointments and insurance authorization of medications/supplies.
Performs and identifies potential adjustment difficulties and provides short-term counseling as needed in clinic.
Demonstrates awareness of cultural challenges and consults with colleagues to develop appropriate treatment plans.
Demonstrates effective communication skills with patients, families, healthcare professionals, and community agencies.
Ability to coordinate a transitional care program that assists patients as they move from pediatric to adult endocrinology care.
Extensive knowledge of diabetes mellitus Type I and II and chronic care needs of pediatric patients.
Knowledge of medical/psychosocial needs of transgender patients and children/families struggling with obesity.
Scheduling flexibility to ensure support for patients/families as needed.
Medical Neighborhood / TC3
Works with clients and multidisciplinary team to identify discrepancies and barriers to health, wellness, and independence towards health equity.
Assesses and utilizes credible tools to evaluate social determinants of health and develop individualized plans of care for clients/families to overcome identified barriers.
Prepares needs assessments and engages team to collaborate services and community resources.
Measures identified barriers, records data, and coordinates all efforts to improve health and wellbeing.
Improves understanding of access points for medical care resulting in decreased use of emergency resources, decreased hospital admission, re-admission, and unnecessary expenditures.
Provides education regarding health promotion and disease prevention or exacerbation.
Acts as navigator and entry point for marginalized community members to essential life-enhancing resources.
Works with clients experiencing behavioral health and/or substance use/abuse, acting as liaison into BH/SU/SA treatment.
Behavioral health, substance abuse/treatment care setting strongly preferred.
Requirements
Education
Masters in Social Work or equivalent required.
Experience
One (1) year of related social work experience.
Licenses/Certifications
HeartSaver First Aid CPR Certification or Basic Life Support (BLS) Certification.
Knowledge, Skills, and Abilities
Knowledge of crisis intervention skills and techniques, psychosocial factors influencing behavior, counseling concepts, and discharge planning.
Skill in evaluating cases and establishing discharge plans.
Ability to complete routine reports and correspondence.
Ability to listen and accurately interpret others' communication or instructions to take appropriate action.
Ability to speak effectively before groups of patients, physicians, or employees of the organization.
Ability to calculate figures and compute rate, ratio, and percent, and to draw and interpret bar graphs; ability to apply basic algebraic concepts.
Ability to define problems, identify data, establish facts, and draw valid conclusions.
Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
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