Care Management Social Worker Nonexempt

Benefits and Perks

• Benefits from Day One:
  Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Full time

Day (United States of America)

400 CELEBRATION PL

CELEBRATION, FL 34747

• Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate.
• Assesses patients’ and families’ wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.
• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Provides patient and family advocacy, and support patient’s choice and patient rights during hospitalization.
• Communicates with Payors patient’s needs for authorization for post-acute care as needed.
• Assesses readmitted patients for the patient’s and family’s perceived reasons for the readmission.
• Other duties as assigned.

• Excellent interpersonal communication and negotiation skills [Required]
• Critical thinking and problem-solving skills [Required]
• Psychosocial assessment skills [Required]
• Customer service skills [Required]
• Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change [Required]
• Effective organizational skills [Required]
• Computer proficiency with Outlook e‑mail and electronic medical records [Required]
• Flexible in a complex and changing healthcare environment [Required]
• Understanding of pre‑acute and post‑acute venues of care and post‑acute community resources [Required]
• Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non‑existent payment resources [Required]
• Strong interview, assessment, and organizational skills [Required]
• Leadership skills [Required]
• Data analysis skills [Required]
• Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement [Preferred]
• Knowledge of state and federal guidelines pertinent to Care Management [Preferred]
• Ability to identify appropriate community resources and to work collaboratively with patients, families, multidisciplinary team and community agencies to achieve desired patient outcomes…