Texas Health Huguley FWS
Overview
Job Title: Social Work Care Manager
Job Number: 25039829
Schedule:
Part-time
Shift:
Days
Benefits All the benefits and perks you need for you and your family:
Benefits from Day One
Paid Days Off from Day One
Student Loan Repayment Program
The role you’ll contribute The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Social Work Care Manager is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Work Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Social Work Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
The value you’ll bring to the team
Assesses patients’ and families’ wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
Qualifications The expertise and experiences you’ll need to succeed:
Required qualifications:
Master's in Social Work (MSW)
3+ years of experience in hospital/medical social work
Preferred qualifications:
Knowledge of state and federal guidelines pertinent to care management.
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Job Number: 25039829
Schedule:
Part-time
Shift:
Days
Benefits All the benefits and perks you need for you and your family:
Benefits from Day One
Paid Days Off from Day One
Student Loan Repayment Program
The role you’ll contribute The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Social Work Care Manager is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Work Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Social Work Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
The value you’ll bring to the team
Assesses patients’ and families’ wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
Qualifications The expertise and experiences you’ll need to succeed:
Required qualifications:
Master's in Social Work (MSW)
3+ years of experience in hospital/medical social work
Preferred qualifications:
Knowledge of state and federal guidelines pertinent to care management.
#J-18808-Ljbffr