Care Management​/Medical Social Work

Job Description

Peace Health is seeking a Care Management/Medical Social Work for a Per Diem/Relief, 0.00 FTE, Day position.

The salary range for this job opening at Peace Health is $38.22 – $57.34. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc.

Cottage Grove is a community of approximately 9,000 people located in the beautiful Willamette Valley, along the Row River, 20 miles south of Eugene and the University of Oregon and serves a population of approximately 25,000 people in the surrounding area. It boasts a modern high school and is the recipient of a national "All-American City Award". Cottage Grove is one of only two cities in the State of Oregon to have received the award twice.

It is also known as the "Covered Bridge Capital of Oregon" – six of the covered bridges in Lane County are located in or around the City of Cottage Grove. The community boasts many outdoor activities, such as hiking, fishing, biking, golfing, boating, and gardening. There are six waterfall hikes within 30 miles, Row River trail (16 mi long), a local live theater, and a downtown historic district.

Annual community events include Historic Home Tours, the Cottage Grove Rodeo, Bohemia Mining Days, and the Family Fun Fair–Western Oregon Exposition.

Responsible for identifying and interacting with medically and psychosocially complex patients and families who are likely to benefit from care management and meet high‑risk criteria and for coordination of discharge planning services for these patients in collaboration with RN Care Management and other members of the care team.

• Screen and identify patients who need care management per high‑risk criteria.
• Assess, develop, implement and monitor a comprehensive discharge plan of care through an interdisciplinary team process in conjunction with the patient and family. Collaborate with the multi‑disciplinary team to identify problems or needs that require special planning, intervention, teaching or follow‑up.
• Identify key problems, strengths and resources to be addressed in the discharge plan of care. Coordinate and facilitate improved ability to comply with plan of treatment; counseling or support needed to cope with situation; improved ability to access appropriate level of care due to lack of financial resources or lack of available service.
• Actively support measures that promote effective use of resources.
• Identify, plan and arrange for appropriate services applying a knowledge of services available in the community, state, and federal health regulations and admission, discharge and appropriate level of care. Coordinate effective planning and arranging for needed services upon discharge.
• Intervene by arranging services, education and providing psychosocial support to prepare the patient and their family to manage their healthcare needs within the acute care setting and post discharge.
• Coordinate with the interdisciplinary team and community resources when appropriate, regarding the multiple details of transitional care management plan. Consult with physician as indicated.
• Works with patients identified and referred to them by RN Care Management and/or other members of the care team, as well as by patients/families.
• Conducts evaluation to include appropriate documentation and the effectiveness of the Care Management services. Collaborates with team members to identify cause and adjust plan if patient’s health status is not improving.
• May counsel patients and/or families to facilitate and/or participate in community care services, in coordination with the physician and treatment team. Works as an integral member of the treatment team in the coordination of treatment and transition of care planning. Assesses and addresses both mental health and chemical dependency conditions. May perform risk assessments for suicidality and homicidality.
• Performs other duties as assigned.

• Bachelor’s Degree
  
  Required:
  
  Social Work or in a related field, with a minimum of four additional…