Case Manager-Social Worker

SUMMARY:

Partners with a multi-disciplinary team to coordinate a plan of care utilizing expertise in counseling, crisis intervention and medical-legal issues, to ensure optimization of health outcomes for patients and their families.  

ESSENTIAL FUNCTIONS:

Assesses, documents, and addresses psychosocial, cultural, emotional, and economic needs of patients and families during the hospitalization and discharge planning process.

Collaborates with the hospital care team, outpatient care team, and community agencies as needed, to creatively resolve issues that could prevent safe and timely patient discharges.

Ensures documentation in the electronic medical record is clear, concise and organized.

Assesses, intervenes, and acts as a resource in medical-legal situations for patients and families.

Identifies community resources and programs appropriate for patients and families.

Develops treatment plans and discusses proposed course of treatment with patient’s primary physician.

Provides follow up on open issues to ensure patient/family /staff concerns are appropriately resolved in a timely manner.

Assists patients and families in making difficult decisions, while honoring their preferences and values, in order to move the discharge plan forward.

Evaluates case management processes to initiate changes when indicated to ensure efficiency and maximize benefit to patient and organization.

Intervenes, as needed, in emotional crisis situations with patients and families.

Performs related duties as assigned.

TMCOne Pediatric Endocrinology clinic:

Coordinates plan of care in a clinic setting.  The Case Manager/Social Worker provides the following in additional to the tasks mentioned above:

• Provides assistance, as needed, to in- patient case management team to ensure timely follow up appointments and insurance authorization of medications/supplies.

• In clinic, performs and identifies potential adjustment difficulties and provides short term counseling as needed.

• Demonstrates awareness of cultural challenges and consults with colleagues to develop appropriate treatment plans.

• Demonstrates effective communication skills with patients, families, healthcare professionals and community agencies.

• Ability, capacity, and experience to implement and facilitate support groups and educational support programs as needed.

• Ability to coordinate a transitional care program which assists patients as they move from pediatric to adult endocrinology care.

• Extensive knowledge of diabetes mellitus Type I and II and chronic care needs of pediatric patients.

• Knowledge of medical/psychosocial needs of transgender patients and children/families struggling with obesity.

• Scheduling flexibility, which may include nights and weekends, to ensure support for patients/families as needed.

   

Medical Neighborhood / TC3:

Works with clients and multidisciplinary team to identify discrepancies and barriers to health, wellness and independence towards health equity.  Assesses and utilizes credible tool to evaluate social determinates of health and develop individualized plan of care for client/family to overcome identified barriers.  Prepares needs assessment and engages team to collaborate services and community resources. Measures identified barriers, records data and coordinates all efforts to improve health and wellbeing.  Improves understanding of access points for medical care resulting in decreased use of emergency resources, decreased hospital admission, re-admission and unnecessary expenditures.  Provides education regarding health promotion and disease prevention or exacerbation.  Acts as navigator and entry point for marginalized community members to essential life enhancing resources.  Works with clients experiencing behavioral health and or substance use/abuse, acting as liaison into BH/SU/SA treatment.  Behavioral health, substance abuse/treatment care setting strongly preferred.

MINIMUM QUALIFICATIONS

EDUCATION:  Masters in Social Work or equivalent required.

EXPERIENCE: One (1) year of related social work experience.

LICENSURE OR CERTIFICATION: HeartSaver First Aid CPR Certification or Basic Life Support (BLS) Certification. 

KNOWLEDGE, SKILLS AND ABILITIES:

• Knowledge of crisis intervention skills and techniques, psychosocial factors influencing behavior, counseling concepts, and discharge planning.

• Skill in evaluating cases and establishing discharge plans.

• Ability to complete routine reports and correspondence.

• Ability to listen and accurately interpret others' communication or instructions to take appropriate action.

• Ability to speak effectively before groups of patients, physicians or employees of organization.

• Ability to calculate figures and compute rate, ratio, and percent, and to draw and interpret bar graphs; ability to apply basic algebraic concepts.

• Ability to define problems, identify data, establish facts, and draw valid conclusions.

• Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.