Social Worker BSW

Summary

The Bachelor of Social Work (BSW) Case Manager plays a pivotal role in maintaining the quality of care patients receive during medical center hospitalization and post discharge while ensuring the organization is fully reimbursed. The BSW Case Manager must have a high level of expertise and skill to create highly effective short‑term and long‑term strategies to prevent readmissions and address unpredictable situations.

The BSW Case Manager is proficient in planning, executing, and monitoring the effectiveness of care to ensure a timely transition through the continuum of care. He or she educates and consults with physicians and the health‑care team to ensure timely and appropriate levels of care. Effective skills in conflict resolution, decision making, and team building are required. The BSW Case Manager practices in accordance with the care‑management process, utilizing tools, standards, models, goals and objectives, and performance‑improvement concepts.

The BSW Case Manager provides pertinent clinical data to outside agencies as needed to assure compliance with their requirements and represents the organization professionally. The ability to analyze, evaluate, and distribute resources and educational information to ensure understanding of services at all educational levels is key to the role. The social worker is responsible for assessing patients’ psychosocial and spiritual needs, education, and discharge‑planning needs.

• (30%) Provide social work intervention related to hospitalization, including crisis management, health‑care decision making, illness adjustment, ethical/legal concerns, discharge planning, transitional care needs, child or elder abuse, domestic violence, competency, financial problems, compliance issues, substance abuse, mental illness, and other psychosocial barriers to maximizing health status.
• (30%) Work with the health‑care team, patient, family, and/or significant others to continually transition the patient to the appropriate level or place of care. Advocate, mediate, and negotiate with an emphasis on patient self‑determination to formulate a cohesive plan for maintaining the patient’s health status, improving social supports, and moving the patient safely into less restrictive and less costly levels of care according to available resources.
• (20%) Collaborate with the physician in competency/capacity determination, obtaining legal guardianship, involuntary psychiatric admission, adoptions, ethical concerns, etc. Complete and disseminate all necessary legal and clinical documentation as needed for resolution.
• (20%) Collaborate with all members of the Care Management Team—including physicians, nurses, health information analysts, and others—to provide information relating to admission, continued stay, discharge criteria, managed care, federal program regulations, reimbursement fundamentals, and regulatory standards on a daily basis.

• Complete and document a standard social‑work psychosocial–spiritual assessment to eliminate barriers to treatment and discharge, increase patient/family satisfaction, and improve appropriate utilization of resources.
• Serve as the lead in obtaining financial and other resources for patients and families in need.
• Identify the need for and conduct family meetings, with or without the physician, that result in understanding, comfort, decision‑making, and other important outcomes such as discharge.
• Integrate relevant theories of family dynamics, crisis intervention, strengths‑based, solution‑focused, and meaning of illness into everyday casework.
• Summarize a patient and family situation concisely, with helpful guidance to non‑social‑work staff members about recommendations for actions to be taken and barriers to discharge.
• Facilitate discharge planning for patients—including extended‑care placements, other facility transfers, and home‑care arrangements—in collaboration with the health‑care team.
• Actively participate in care‑coordination efforts to identify high‑risk factors and respond appropriately so that key information, next steps, and avoidable days are captured and documented.
• Participate…