Care Navigator Acute Social Worker

Major Responsibilities

• Participates in rounds on the patient care unit with the attending physician and other members of the health care team; coordinates communication to assure collaboration and consistency in moving the patient’s care to estimated date of discharge.
• Assesses patients to determine their discharge planning and/or post‑acute transition needs. Develops the discharge plan and works with the physician to implement the plan utilizing internal and external resources to ensure a safe discharge or transition to alternate level of care. Plan will address the following: assessment of patient’s physical, functional, social and psychological status; assessment of cultural and language needs;
  
  assessment of caregiver resources and available benefits.
• Assigns the appropriate care pathway based on the clinical feedback from the physician and the diagnosis‑DRG. Ensures coordination of services among the patient’s physicians, specialists, community agencies and vendors. Works collaboratively with patient’s physicians and members of the multidisciplinary team to assure communication and exchange of input related to patient’s specific care needs. Utilizes clinical judgment, independent analysis, evidence‑based clinical guidelines, patient preference, and input from interdisciplinary team in making decisions.
• Assesses progress toward goals and identifies barriers to meeting goals. Prepares and maintains appropriate documentation of patient care and progress within the designated systems. Closes cases in accordance with defined case closure procedure in a timely manner and in accordance with established guidelines. Refers cases for post‑discharge follow up to the Care Navigator‑Outpatient.
• Advocate in the patient’s best interest for necessary funding, treatment alternatives, timelines and coordination of care, with frequent evaluations of progress and goals. Continues to identify community and caregiver resources to ensure continuity of care during and after completion of the care management plan.
• Integrates patient‑centered care into the nursing processes to include the patient(s) and family in care decisions, incorporating evidence based practices to achieve safe and effective patient and process outcomes. Communicates plan of care to patient and family and solicits concerns, questions, and issues for resolution.
• Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
• Performs Utilization Management duties as indicated by the UM Plan and the payer requirements. Acts as a liaison between the Precert Team and the physician.
• Performs all duties related to utilization review as mandated by Navicent Health UM plan and by regulatory agencies such as DNV, CMS, Payers, DCH, etc.
• Works with Physician to establish the appropriate admission status for billing. Ensures all aspects of the process are addressed from a CMS compliance standpoint. Issues the IMM notice to discharging patient.
• Monitors Care Pathways entering clinical information into the system and using an established UR criterion. Makes referrals to the UM Physician Advisors as per policy. Works with Attending Physician to ensure changes to status are supported by order and documentation.
• Track utilization of professional services, service delays, discharge delays, etc and reports as necessary. Provides collaboration with the Attending Physician to work through the delays.

Certification in Care/Case Management preferred.

Bachelor’s degree in Social Work, Master’s preferred.

Minimum of three years of recent experience in acute care, home health, case management, discharge planning or care management. Experience as a Care Manager preferred. Experience with IT solutions such as electronic health record, learning management or disease/care management systems a plus.

NA

Must be able to use visual…