The Social Worker Care Manager is responsible for providing appropriate interventions and discharge planning services to patients and families and facilitates a smooth transition for the patient throughout the continuum of care by accessing hospital, community, and governmental resources. They also provide clinical supervision to peers, Social Workers, and students.

Essential Functions:

• Identifies and prioritizes patients in need of social services, using a holistic approach inclusive of biopsychosocial, functional, cultural, spiritual, and financial factors. Plans with the patient, caregivers and members of the healthcare team to maximize health care responses, quality and cost-effective outcomes. Monitors and revises the plan as indicated when patient condition changes.

• Completes all necessary documentation. Maintains, clear, concise, and timely documentation in the patient record to reflect the needs of the patients.

• Documentation will reflect plan of care to address post hospital care needs and resources and evidence of patient, family, or caregiver involvement in planning. Ensuring patient’s and caregiver’s treatment goals and preferences are incorporated into the transition of care planning and communicated to the multidisciplinary team.

• Follow standardized practices and process related to Advance Care Planning, Length of Stay management and readmission prevention.

• Supports denial prevention related to medical necessity through addressing / removing barriers to progression of care and participating in Interdisciplinary Discharge Rounds.

• Supports and promotes assertive, proactive care for patients, assisting in removing barriers related to achieving timely testing and treatment. Ensures resources are utilized appropriately and offering alternatives to acute care to the care team.

Education:

• Bachelor of Social Work (required)

• Master’s degree in social work or healthcare related field (preferred)

Licensure/Certification:

• BLS Basic Life Support – American Heart Association (required)

• Licensed as a Social Worker in state of practice (required, preferred in VA)

• Accredited Case Manager Certification (ACM) from American Case Management Association or Certified Case Manager (CCM) from Commission for Case Manager Certification (preferred)

Experience:

• 1 year of experience in clinical setting (required)

• 3 year of experience in an acute care clinical setting (preferred)

• Ambulatory or post-acute, care coordination experience (preferred)

Training:

None

Skills and Abilities:

Hard/Tech/Clinical Skills:

• Social Work

• Care Management

• Ethics

• End of Life Ethics

• Patient Advocacy

• Clinical Supervision

• Microsoft office

• Ability to prioritize many simultaneous demands and tolerate frequent interruptions.

Soft/Interpersonal Skills:

• Attention to detail

• Critical thinking

• Communication with family members

• Conflict resolution

• Active listening

• Relationship building

• Effective problem solving

• Teamwork

• Open to change

• Collaboration

• Communication

• Displays empathy

• Negotiation skills

• Time management

• Prioritization