Case Manager-Social Worker
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.
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.
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.
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.