This position will work 20 hours per week, 8-hour shifts from 8am to 4:30pm, schedule will need to be flexible in order to meet the needs of the OB and Pediatric patient population with flexibility to back-up on other inpatient floors if needed.
The Case Manager/Social Worker reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
- Develops individualized treatment plans for patients, in collaboration with the patient, their family and the health care team.
- Coordinates and leads care conferences on patients with length of stays greater than 7 days.
- Documents unusual occurrences and patient relations issues; makes appropriate referrals to risk management, infection control and quality departments.
- Assesses patient and family needs for appropriate discharge services.
- Coordinates transfer to appropriate level of care such as skilled care, rehabilitation, custodial and home health care for complex care.
- Documents discharge planning on the interdisciplinary plan of care, in progress notes and education record (when applicable).
- Maintains current knowledge of resources available in the community to support a continuum of effective services for the patient.
- Delivers notice of Medicare discharge appeal rights within the appropriate time frame.
- Delivers detailed notice of discharge upon discharge appeal for social work cases
- Performs medical record review to assess for appropriateness of admissions and continued hospital stay for assigned patients.
- Monitors avoidable days and recommends change in services or processes.
- Ensures compliance with managed care contracts and length of stay targets while maintaining quality of care.
- Develops and educates staff to reduce length of stay and resource consumption while maintaining quality of care.
- Distributes hospital issued non coverage notices.
- Identifies appropriate cases requiring social work services.
- Collaborates with physicians and other healthcare personnel in patient evaluation and treatment to further their understanding of significant social and emotional factors underlying patient's health problems.
- Advocates for patients’ rights within the healthcare community to access resources to improve compliance and quality of life
- Identifies and validates patient and family psychosocial needs that impact compliance to medical treatment plan through individual or group conferences to help the patient understand, accept and follow medical recommendations
- Provides appropriate services and referrals to restore and motivate the patient to seek optimum social and health adjustment within the patient's capacity.
- Utilizes available community resources to assist patients to resume their lives in the community and to learn to adapt within limits of disability.
- Prepares patient histories, service plans and reports; provides consistent, accurate documentation of social work activities.
- Provides emotional support and counseling to patients and their families to assist them in coping with illness, hospitalizations, the dying process, and financial management.
- Reports abuse, neglect, domestic violence and other required cases to appropriate authorities and provides education and guidance to other mandated reporters when they encounter abuse and neglect patient cases
- Assists with transfer of patients to appropriate treatment facilities including substance abuse and psychiatric facilities.
- Initiates discussions with families regarding organ and tissue donation; facilitates referrals to appropriate agencies.
- Serves as a liaison to the ethics committee and actively assists patients and families with decision making involving complex ethical questions.
- Performs crisis intervention with patient and family situations; responds to crisis situations in the ER and ICU.
- Assesses and transfers patients with acute psychiatric illness who require inpatient psychiatric care to the appropriate facility
- Assesses at risk patients for goals of care conversations and initiates conversations
- Communicates plan of care with attending physician and interdisciplinary teams
- Develops programs and educates patients and families on advance directives.
- Provides patient, staff and community education on topics related to health and psychosocial issues.
- Member of the Palliative Medicine and Supportive Care interdisciplinary team
- Participates in PMSC care conferences, Goals of Care conversations, and family meetings
- Performs all discharge planning duties for inpatient PMSC patients
- Primary social work source for inpatient PMSC patients for care coordination, providing emotional support, community resource allocation, and communication between the inpatient and PMSC outpatient social work team