Social Work Care Manager, Registry

Overview

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• Comprehensive health benefits that start day 1
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• Family-focused benefits
• Wellness incentives

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JOB DESCRIPTION:

The Social Work Care Manager (PRN) is responsible for patient care coordination from admission through discharge; ensuring smooth transitions of care as the patient is discharged from the hospital setting, ensuring and facilitating high quality clinical and cost outcomes, procuring and securing post-acute services, coordinating and advocating for patients and families with both internal and external stakeholders, and identifying and addressing potential barriers to care coordination/discharge planning in an effort to foster efficient care delivery and maximize reimbursement.

The SW CM (PRN) will begin the process of care coordination at the time of the patients admission by completing a thorough admission assessment and/or psychosocial assessment which will allow for a timely and accurate capture of information as well as foster the ability to begin working towards a discharge plan. The Registry SW CM (PRN) is an integral part of the interdisciplinary care team who is required to attend rounds, care conferences, and/or care team meetings.

The Registry SW CM (PRN) will act as a representative of both the hospital care team and the patient/family in an effort to balance patient/family choice and projected care coordination needs with the ability to execute such services. The SW CM (PRN) will work with the hospital care team and the patient/family in order to plan and implement the best possible plan for the patient while taking various factors, limitations, and patient/family preference into consideration.

The SW CM (PRN) will identify post-acute services and will complete referrals to appropriate post-acute care providers in a timely manner, coordinating directly with the patient/family as well as the care team. Through continuous assessment and review, the SW CM (PRN) will apply critical thinking to ensure alignment and appropriateness of post acute services as the patient clinically progresses throughout their stay.

Ultimately, the SW CM (PRN) is responsible for ensuring the discharge plan is aligned to be executed with the patients medically cleared for discharge date as well as the projected length of stay as provided by the payor. The SW CM (PRN) identifies and participates in the development of strategies to reduce unnecessary length of stay and/or resource consumption. The SW CM (PRN) escalates cases, as appropriate, to management, Physician Advisor, Complex Care team and/or Ethics committee.

It is the role of the SW CM (PRN) to educate patients/families as well as the care team as it relates to post acute services, transitions of care, readmission mitigation, appropriate post-acute level of care choices and available resources. The SW CM (PRN) provides supportive and therapeutic communication for patients, families and loved ones who are experiencing anxiety or stress due to illness, injury or physical limitations.

The SW CM responds to suspected violent, assault, abuse and/or neglect cases in accordance with social work professional ethics. The SW CM (PRN) must communicate confidently, effectively, and therapeutically while being assertive and conveying an impression which reflects favorably upon the organization. In…