Medical Social Worker Case Manager

JOB SUMMARY

Assists patients and their families in coordinating medical, social, emotional, insurance, and vocational issues related to injury or illness. Conducts psychosocial assessments, either in
-person or telephonically, in order to develop a comprehensive out-patient care plan that guides work with patient. Collaborates with physicians, nurses, support staff, community agencies, and other health care professionals to implement safe, effective, and timely patient care. Communicates with treating clinicians on areas of concerns and provides clinical updates to clinicians on a regular basis. Provides timely and appropriate documentation in patient's electronic medical record.

Participates in assuring that the client is in the forefront of applying Case Management principles. Participates in achieving the goal of cost effective, high quality, continuous care to patients; communicates effectively with clinicians, patients, and team leader to achieve this goal. Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services.

Maintains quality assurance and improvement activities in compliance with client standards. Assists in development of reports and resources required by other departments.

• Assumes responsibilities of an active caseload, including following patients throughout the continuum of care.
• Provides Ambulatory Case Management services to identified patients through a process of research, patient interview, development of care plans and monitoring of care.
• Researches clinical history of identified patients using all necessary and appropriate resources.
• Provides a clinical assessment either telephonically or as appropriate in person to assess patient’s needs and perception of their health status.
• Provides pre-operative outreach and assessment to identified student athletes.
• Assists patients and their families coordinate medical, social, emotional, insurance, and vocational issues related to injury or illness.
• Educates patients and families regarding Advance Directives and assists patients and families in completing Advance Directives.
• Promotes effective communication with hospitals and their departments. Educates them to resources available at the Client Health Services.
• Participates in/attends IM Team Meetings and daily huddles.
• Participates in/attends client committees/work groups when appropriate.
• Communicates with primary care clinician, patient, and home care provider to ensure medically necessary services. Regularly communicates with patients requiring post- discharge service to assess patient satisfaction and that appropriate services are in place.
• Evaluates utilization and effectiveness of Home Care provider network.
• Assess quality of care of Home Care providers as well as responsiveness. Addresses areas of concerns with manager to ensure optimal quality of care for patients.
• Educates patients/families about non-skilled services for patients when necessary. Assists in arranging for these services when patients/families allow.
• Acts as a liaison between patients and the client to assist in coordinating follow up services.
• Ensures the department maintains effective communication with other Client Departments.
• Educates client staff about Care Coordination’s scope of service and how to utilize client case managers as resources.
• Identifies areas of improvement; recommends and implements solutions.
• Actively participates in project development. Collaborates with manager to implement, evaluate, and support programs to maximize utilization of available resources.
• Assists in maintaining a Quick Reference Resource Guide.
• Educates patients/families/caregivers as to…