AdventHealth
Social Work Care Manager, Part-Time Weekends
AdventHealth, Overland Park, Kansas, United States, 66213
Social Work Care Manager, Part-Time Weekends
AdventHealth South Overland Park
Schedule Part-Time Weekends
Saturday Sunday (weekend shift) hours from 8-4
Location AdventHealth South Overland Park
Benefits
Vision, Medical & Dental Benefits from Day One
Student Loan Repayment Program
Received Magnet recognition from the American Nurses Credentialing Center in January 2019
Role Responsibilities The Social Work Care Manager intervenes with patients who have complex psychosocial needs, requires assistance with eligibility determination for social programs, funding sources and qualifies for community assistance from a variety of special assistance programs and agencies, and/or requires assistance with transitions of care or discharge planning. In addition, offers 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.
Receives 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).
Collaborates with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team to ensure patient-centered care coordination through the continuum of care.
Ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations.
Responsible for patient evaluations of post-hospital needs; development of a transition of care plan and initiation of the implementation prior to discharge.
Ensures optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management.
Communicates daily with the interdisciplinary team during daily multidisciplinary rounds.
Facilitates collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement.
Provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS Coordinated Care for Discharge Planning and care coordination.
Maintains knowledge of post-hospital care and services available to the patient including, but not limited to: 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.
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 maintains respectful relationships with all.
Value You’ll Bring To The Team
Psychosocial Assessment and Interventions
Assesses patients' and families' psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, assisting those coping with adjusting to significant life transitions.
Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs.
Serves as a resource to provide information and intervention related to treatment decisions, terminal illnesses and end-of-life issues.
Provides grief counseling and crisis intervention skills.
Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system.
Provides de-escalation services for patient/family as appropriate.
Provides Motivational Interview techniques for patients with substance use and additive disorders.
Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention.
Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis.
Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers.
Receives referrals for psychosocial complex needs from the health care team.
Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.
Provides consult services for patients who may possibly lack decision-making capacity; coordinates with Care Management leadership throughout the process.
Assists the health care team in the patient assessments and placements for mental health services.
Facilitates full team discussion including patient and family when ethical dilemmas arise.
Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed.
Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures.
Reviews necessary patient information including labs, medications (pre and post hospital), history and physical, therapy notes, ED notes, test results and progress notes.
Incorporates the patient/family care goals and preferences into the transition of care planning and communicates these to the multidisciplinary team.
Incorporates clinical, social and financial factors into the transition of care plan.
Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.
Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions.
Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds.
Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's readmission risk scores and coordinating readmission mitigation interventions.
Ensures Social Work consults are completed for specialty services related to psychosocial needs, decision-making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
Escalates issues and barriers to appropriate level of Care Management leadership.
Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
Facilitates patient care conferences with multidisciplinary team as needed.
Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition and destination and updates as needed.
Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
Collaborates with Utilization Management staff for medical necessity discussions.
Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care.
Ensures reassessment of discharge needs provided anytime a patient's condition changes or circumstances impacting post-hospital care change.
Ensures patient notifications are provided and documented for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
Communicates with patient/family the possible need to pay for services out of pocket.
Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post hospital follow up care.
Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
Participates in department and hospital Performance Improvement activities.
Provides necessary patient care coverage and assistance with other duties as assigned when needed.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
Participates in facility and department regulatory and certification preparations.
Social Work Care Manager serves as a preceptor.
Social Work Care Manager participates in department education (bulletin or presentation) with topic and content approved by Facility CM Director.
Qualifications
Excellent interpersonal communication and negotiation skills
Critical thinking and problem-solving skills
Psychosocial assessment skills
Customer service skills
Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open minded and adaptable to change
Effective organizational skills
Computer proficiency with Outlook e-mail and electronic medical records
Flexible in a complex and changing healthcare environment
Understanding of pre-acute and post-acute venues of care and post-acute community resources
Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources
Strong interview, assessment, and organizational skills
Leadership skills
Data analysis skills
Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement
Knowledge of state and federal guidelines pertinent to Care Management
Ability to identify appropriate community resources and to work collaboratively with patients, families, multidisciplinary team and community agencies to achieve desired patient outcomes
Education and Experience Required
Masters and 3 years experience
Masters in Social Work (MSW)
Minimum three (3) years experience in hospital/medical social work
Care Management discharge planning experience
Knowledge of state and federal guidelines pertinent to care management
Licensure, Certification or Registration Required
Licensed Clinical Social Worker (LCSW)
ACM/CCM certification
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.
We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.
#J-18808-Ljbffr
Schedule Part-Time Weekends
Saturday Sunday (weekend shift) hours from 8-4
Location AdventHealth South Overland Park
Benefits
Vision, Medical & Dental Benefits from Day One
Student Loan Repayment Program
Received Magnet recognition from the American Nurses Credentialing Center in January 2019
Role Responsibilities The Social Work Care Manager intervenes with patients who have complex psychosocial needs, requires assistance with eligibility determination for social programs, funding sources and qualifies for community assistance from a variety of special assistance programs and agencies, and/or requires assistance with transitions of care or discharge planning. In addition, offers 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.
Receives 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).
Collaborates with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team to ensure patient-centered care coordination through the continuum of care.
Ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations.
Responsible for patient evaluations of post-hospital needs; development of a transition of care plan and initiation of the implementation prior to discharge.
Ensures optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management.
Communicates daily with the interdisciplinary team during daily multidisciplinary rounds.
Facilitates collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement.
Provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS Coordinated Care for Discharge Planning and care coordination.
Maintains knowledge of post-hospital care and services available to the patient including, but not limited to: 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.
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 maintains respectful relationships with all.
Value You’ll Bring To The Team
Psychosocial Assessment and Interventions
Assesses patients' and families' psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, assisting those coping with adjusting to significant life transitions.
Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs.
Serves as a resource to provide information and intervention related to treatment decisions, terminal illnesses and end-of-life issues.
Provides grief counseling and crisis intervention skills.
Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system.
Provides de-escalation services for patient/family as appropriate.
Provides Motivational Interview techniques for patients with substance use and additive disorders.
Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention.
Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis.
Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers.
Receives referrals for psychosocial complex needs from the health care team.
Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.
Provides consult services for patients who may possibly lack decision-making capacity; coordinates with Care Management leadership throughout the process.
Assists the health care team in the patient assessments and placements for mental health services.
Facilitates full team discussion including patient and family when ethical dilemmas arise.
Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed.
Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures.
Reviews necessary patient information including labs, medications (pre and post hospital), history and physical, therapy notes, ED notes, test results and progress notes.
Incorporates the patient/family care goals and preferences into the transition of care planning and communicates these to the multidisciplinary team.
Incorporates clinical, social and financial factors into the transition of care plan.
Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.
Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions.
Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds.
Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's readmission risk scores and coordinating readmission mitigation interventions.
Ensures Social Work consults are completed for specialty services related to psychosocial needs, decision-making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
Escalates issues and barriers to appropriate level of Care Management leadership.
Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
Facilitates patient care conferences with multidisciplinary team as needed.
Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition and destination and updates as needed.
Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
Collaborates with Utilization Management staff for medical necessity discussions.
Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care.
Ensures reassessment of discharge needs provided anytime a patient's condition changes or circumstances impacting post-hospital care change.
Ensures patient notifications are provided and documented for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
Communicates with patient/family the possible need to pay for services out of pocket.
Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post hospital follow up care.
Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
Participates in department and hospital Performance Improvement activities.
Provides necessary patient care coverage and assistance with other duties as assigned when needed.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
Participates in facility and department regulatory and certification preparations.
Social Work Care Manager serves as a preceptor.
Social Work Care Manager participates in department education (bulletin or presentation) with topic and content approved by Facility CM Director.
Qualifications
Excellent interpersonal communication and negotiation skills
Critical thinking and problem-solving skills
Psychosocial assessment skills
Customer service skills
Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open minded and adaptable to change
Effective organizational skills
Computer proficiency with Outlook e-mail and electronic medical records
Flexible in a complex and changing healthcare environment
Understanding of pre-acute and post-acute venues of care and post-acute community resources
Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources
Strong interview, assessment, and organizational skills
Leadership skills
Data analysis skills
Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement
Knowledge of state and federal guidelines pertinent to Care Management
Ability to identify appropriate community resources and to work collaboratively with patients, families, multidisciplinary team and community agencies to achieve desired patient outcomes
Education and Experience Required
Masters and 3 years experience
Masters in Social Work (MSW)
Minimum three (3) years experience in hospital/medical social work
Care Management discharge planning experience
Knowledge of state and federal guidelines pertinent to care management
Licensure, Certification or Registration Required
Licensed Clinical Social Worker (LCSW)
ACM/CCM certification
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.
We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.
#J-18808-Ljbffr