Social Worker Case Manager

16 hours ago


Aragüés del Puerto, Huesca, United States Inova Health System Full time
Job Title: Social Worker Case Manager

The Social Worker Case Manager plays a vital role in evaluating the ability of patients to progress throughout the continuum of care. Working collaboratively with physicians, nursing, and other members of the multidisciplinary care team, this individual ensures timely and appropriate patient management. Demonstrating a working knowledge in utilization management, managed care, and payer issues, the Social Worker Case Manager provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting, with a deep understanding of pre/post-acute resources.

Key Responsibilities:
  • Participate in the assessment of patients' biopsychosocial needs through review of patient information, personal contact with patients/families, and interdisciplinary care team members. Communicate routinely with patients, families, interdisciplinary care team members, and other appropriate parties regarding the status of patients' care plans, progress toward treatment goals, identification of concerns and/or problems, problem-solving, and assisting with conflict resolution when necessary.
  • Ensure that all options available to support a successful transition and elements critical to patients' care plans have been communicated to patients/families and members of the healthcare team and are documented as necessary to ensure continuity of care. Refer cases and issues appropriately to resolve barriers to care progression. Act as an advocate for patients to resolve barriers to care progression.
  • On the basis of preliminary risk screenings, assess the psychosocial risk factors of patients/families through the evaluation of prior functional levels, appropriateness/adequacy of support systems, reactions to illnesses, and the ability to cope.
  • Intervene with patients/families regarding emotional, social, and financial consequences of illness and/or disability.
  • Serve as a resource person and provide counseling and interventions related to treatment and end-of-life decisions. Advocate for patient/family empowerment and independence to make autonomous healthcare decisions and access needed healthcare services.
  • Provide discharge planning and continuity of care for assigned patients in the acute and post-acute settings.
  • Initiate and facilitate referrals to clinics, home healthcare, hospice, SNF, acute rehab, LTAC, TCM, medical equipment, and supplies as indicated.
  • Collaborate with the interdisciplinary care team, patients, and families in the assessment/coordination of discharge planning needs, delivery of post-discharge planning needs, delivery of post-discharge services, and transition of patients from the hospital to the discharge setting as well as ongoing care in the community.
  • Document relevant discharge planning information in the medical record according to department standards and/or care management plans. Collaborate/communicate with internal/external Case Managers.
  • Provide coordination of services and act as a key Liaison between patients, families, and the interdisciplinary healthcare members.
  • Perform other duties as assigned.
Requirements:
  • MSW in Social Work
  • Basic Life Support through the American Heart Association
  • One year of experience in clinical care or clinical case management


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