Social Worker Case Manager - Per Diem

MCH
452 Old Street Rd
Peterborough, NH 03458, USA

At MCH, you'll collaborate with a diverse and knowledgeable team, contributing to the high-quality care we provide to our community. We value your passion for patient care and teamwork.

The SW Case Manager is responsible for working with patients, families and interdisciplinary care team members with the overall goal of developing transitional care plans that are patient-centered and respect patients’ individual needs, values and goals, and are developed in alignment with available resources.

The SW Case Manager performs Care Coordination activities as further described below consistent with The National Association of Social Workers (NASW) Standards of Practice in Health Care Settings.

Located in the scenic Monadnock Region of New Hampshire, Monadnock Community Hospital (MCH), a trusted healthcare partner in Peterborough, NH, is dedicated to enhancing the health and well‑being of our community. We provide compassionate, personalized care, from Primary Care, Inpatient & Outpatient Services, to a range of specialties such as Cardiology, Behavioral Health, Gastroenterology, Obstetrics, Ophthalmology, Orthopedics, and more. Our 24/7 emergency department, full laboratory, and radiology department round out our commitment to delivering high‑quality patient care.

Driven by innovation, MCH offers cutting‑edge programs to keep the community healthy.

Develops and coordinates inpatient discharge plans for patients who are considered at risk for adverse outcomes (e.g., readmission, medication error, falls) as determined by the interdisciplinary care team and in collaboration with the RN UR/Case Manager and other members of the care team, such as physicians, nurses, pharmacy, therapy, Primary Care social workers, etc.

• Assesses all inpatients including those on the Birthing Suite and Med Surg Unit to determine the need for services post‑discharge as soon after admission as possible (preferably within one day of admission with the exception of weekends/holidays).
• Identifies patients who require discharge planning services through chart review and through information gathered through conversations with the interdisciplinary team and with patients and families, and through discussions at care rounds.
• Collaborates with the interdisciplinary team and the patient and family, as appropriate to develop a plan.
• Follows up with plans identified by Master’s level social workers for those patients that are hospital patients.
• Makes referrals to health care providers, nursing facilities and agencies to transition care to the post‑discharge.
• Documents all discharge planning activities in the medical record.
• Arranges for family meetings, as appropriate.
• Completes documentation as required by nursing facilities, by DHHS and others to facilitate the patient’s discharge to other care settings.
• Assists in identifying cost savings for treatment consistent with payor requirements and consistent with patient financial resources to mitigate cost of care (i.e., medications; equipment; post‑acute providers).

Provides information and advice to outpatient areas, such as the Emergency Department and other areas where patients are identified to be in need of services, such as skilled care or home care.

When providing outpatient advice, the SW Social Worker will consult with primary care social workers to determine whether patients are already under the care of MHP so that appropriate hand‑offs can be made.

Participates in internal and external quality improvement activities, reports adverse events and adheres to safety practices, reports accidents/hazards and maintains equipment as outlined in hospital policies.

• Education: A Bachelor’s degree in social work from a college accredited by the Council on Social Work Education is required, with preference given to a candidate that is certified and/or working towards a Master’s degree.
• Experience: 1–2 years experience in a hospital setting required.
• Required Skills: Must have excellent interpersonal skills and the ability to communicate effectively through various means with a variety of individuals, including physicians,…