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Social Services Care Coordinator
2 months ago
Position Overview:
The Social Work Care Manager is responsible for conducting evaluations and interventions aimed at assisting clients and their families in overcoming social and economic challenges that hinder their health and wellness. This role utilizes case management processes, strategies, and community resources to facilitate effective support.
Provides expert discharge planning services through comprehensive assessments and coordination of post-hospital care requirements for patients and their families, ensuring they have access to necessary resources and options for emotional, medical, and spiritual support.
Receives referrals for individuals from vulnerable populations through interdisciplinary team collaboration.Key Responsibilities:
Conducts thorough triage of all patients, focusing on identifying those with intricate psychosocial or financial challenges, placement requirements, and community service needs within 24 hours of admission.
Processes RN Care Manager referrals to social work based on established 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 patient and family requirements for support and community services (e.g., Meals on Wheels, Sitters); educates and connects them to community resources, arranges appointments, and builds relationships with other agencies.
Evaluates the risk of readmission for specific patient populations and initiates interventions to enhance the patient's ability to transition successfully along the care continuum.
Identifies the need for, organizes, and participates in family care conferences; engages in interdisciplinary meetings and provides consultation for patients, families, and clinical staff.
Recognizes patient and family preferences, needs, and strengths to support the interdisciplinary team in adhering to care standards.
Conducts interviews with patients and significant others to assess the psychosocial situation and determine the primary family contact.
Manages complex cases and advocates for patients and families as care and discharge plans are developed.
Utilizes knowledge of insurance benefits and coverage guidelines to optimize resource utilization.
Documentation:
Records assessments, plans, interventions, barriers, and reassessments in the EMR to facilitate discharge and transitions; ensures all relevant information is communicated to post-acute care agencies.
Collaborates with the RN Care Manager, other disciplines, and internal and external healthcare team members to ensure a safe, appropriate, and timely transition to the next level of care, considering the patient's available resources.
Partners with external agencies and facilities to maintain continuity of care, empowering patients and families to make informed health decisions.
Performs additional related duties as required.
Qualifications:
Required:
Licensed Master's Social Worker (LMSW); LMSW certification within one year of eligibility and adherence to continuing education requirements.
American Case Management Certification (ACM) or obtain certification when eligible as defined by the Association Case Management Association, with ongoing education requirements.
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 by recognized organizations.
Knowledge, Skills, and Abilities:
Ability to manage crisis situations effectively in a fast-paced environment.
Proficient in multitasking, organizing, prioritizing, and completing work within tight deadlines.
Ability to engage with patients of diverse personalities.
Proficient in using computers, monitors, keyboards, and mice; capable of typing.
Ability to address practical problems and navigate various concrete variables in situations with limited standardization.
Competency in applying the principles, methods, materials, and equipment necessary for effective case management services.
Adherence to the Code of Ethics and Guide for Professional Conduct.
Current knowledge of treatment theories, practices, and techniques relevant to the discipline.
Customer-focused attitude with the ability to work proactively and efficiently with appropriate urgency.
Demonstrated ability to read and interpret documents such as safety rules, operating instructions, and policy manuals.
Knowledge and proficiency in utilizing computerized hospital/health information management systems and software applications (e.g., Cerner, Paragon, Meditech, InterQual, Optum) and Microsoft Office Suite.
Maintains knowledge of applicable CMS rules and billing regulations related to Medicare, Medicaid, and commercial insurance.
Ability to work independently, employing problem-solving techniques and critical thinking skills.
Availability for weekend, holiday, and evening coverage as required.
