Social Worker- Care Management

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Complete patient assessments to evaluate all social, psychological, or environmental needs related to the impact of admission, diagnosis, treatment, or discharge.
• Provide patient/caregiver with education, information, and referral services. Provide patient/caregiver with relevant information about medical illness, behavioral health, insurance coverage, support, and community services.
• Develop plan of care for patients in collaboration with the primary care team. Document in the medical record as indicated and designated case management tool accurately.
• Provide ongoing communication between the patient and health care team to ensure improved patient outcomes and high quality of patient care. Conduct end-of-life discussions with patient/family, as needed.
• Facilitate referrals to other disciplines and internal health and community based programs as needed to improve patient outcomes. Coordinate and participate in interdisciplinary patient/caregiver conferences.
• Participate in departmental process improvement initiatives, work on special projects as needed and attend all departmental meetings.
• Serve as an advocate and resource for the patient/caregiver.
• Provide temporary case management to a specified case load.
• Qualifications

A. Experience, Education, Licensures & Certifications

B. Knowledge, Skills & Abilities

• Proficient in computer software and usage including but not limited to Microsoft Outlook and Microsoft Excel
• Knowledge of community resources and behavioral needs for adult population
• Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management and quality improvement
• Demonstrate awareness and ability to work alongside diverse cultures and patient populations
• Ability to create positive working relationships with physicians and other members of the health care team
• Ability to demonstrate work toward the progress of patient- centered goals
• Ability to adapt to changing environment
• Ability to work independently and within a team environment with minimal supervision
• Excellent negotiation and advanced conflict resolution skills
• Strong analytical, organizational, and time management skills
• Strong written and verbal communication skills; ability to communicate effectively in stressful situations
• Self-disciplined, energetic, passionate, and innovative
• Decision making/problem solving and training/teaching skills
• Critical and ‘systems' thinker with strong attention to detail