Tuba City Regional Health Care Corporation
Lead Social Worker / RN Case Manager (DH2110)
Tuba City Regional Health Care Corporation, Tuba City, Arizona, us, 86045
Overview
POSITION SUMMARY
Incumbent serves as Lead Social Worker/Registered Nurse (RN) Case Manager for TCRHCC and Sacred Peaks Healthcare Center (SPHC) and is responsible for direct supervision and supportive contact for the specific group of identified high-risk patients. The Lead Social Worker/RN Case Manager assists the Director of Care Coordination with management of the MSW and Case Managers with onboarding program, day-to-day assignments, routine reporting, and supervisory duties. Designs and manages a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency. Responsibilities include assessment, service planning, and resource acquisition, monitoring progress, and initiating and responding to emerging client needs. The Lead Social Worker/RN Case Manager links clients with Community Social Service providers, health care providers, substance abuse, and mental health providers to achieve goals. This role works with culturally diverse low-income populations facing barriers such as illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. The Lead Social Worker/RN Case Manager works with a multidisciplinary team and may have assignments related to Purchased and Referred Care (PRC), providing assistance to the PRC Case Specialist. This role reports to the Director of Case Care Coordination.
Qualifications NECESSARY QUALIFICATIONS
Education:
MSW Social Worker: Master’s Degree in Social Work (MSW), OR
RN Case Manager:
Associates degree in Nursing
License/Certification:
Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association throughout employment
MSW Social Worker:
Licensed Master Social Worker (LMSW) OR
RN Case Manager:
A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
Experience:
Must have a minimum of three (3) years of experience in the clinical care setting or with case management.
Demonstrate knowledge of electronic health record systems.
Other Skills and Abilities:
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each of the following areas:
Positive working relationships with others
Possession of high ethical standards and no history of complaints
Reliable and dependable; reports to work as scheduled without excessive absences
Effective verbal & written communication skills
Team management focus promoting a positive and proactive approach to problem resolution
TCRHCC confirms the applicant can perform the essential functions of the job
Successful completion of and positive results from all background and reference checks, including fingerprint clearance requirements, physical examinations, and other screenings indicating qualification to be employed by TCRHCC
Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information
MENTAL AND PHYSICAL EFFORT Physical:
This position requires an individual of high energy who can maintain a long and flexible schedule. Physical requirements include sitting for long periods, frequent walking, occasional driving, climbing, bending, kneeling, crouching, twisting, balance, and reaching. Ability to hear, speak, and understand others; lift up to 35 lbs; push/pull up to 10 lbs; and vision requirements including color and depth perception. Keyboard use and fine motor manipulation are required.
Mental:
Uses independent judgment and analytical skills to make decisions impacting operations, finances, and customer service. Ability to work in structured and unstructured environments, maintain attention to detail, handle multiple priorities in stressful situations, and manage shift work. Must cope with high levels of stress and communicate calmly in challenging situations.
Environmental:
May be exposed to chemical agents, extreme temperatures and humidity, infectious diseases, dust, fumes, hazardous equipment, and loud noises.
ESSENTIAL FUNCTIONS
Responsible for assisting the Director of Care Coordination, managing the MSW and Case Managers with onboarding program, day-to-day assignments, routine reporting, and supervision of staff.
Coordination of service-specific assessments, service planning and enrollment
Works with all facets of the Case Management continuum, including social support, alternate resources, community referrals, discharge planning, Nursing Home/Skilled Nursing Placement and resource utilization.
Comprehensive and client-centered service planning and coordination
Work proactively with the established RN Case Managers/Social Workers of TCRHCC as a team member for care coordination of the patient populations served by TCRHCC
Resource acquisition, facilitate referrals and connect clients to those resources and referrals
Consistent and ongoing case consultation with all direct service providers
Develop and maintain internal and external resource relationships
Responsible for service monitoring and following up to ensure continuity of care and updating the client service plan
Identify patient needs through consultation and high-risk diagnoses, e.g., COPD, CHF, DM
Assist with the development of department reports, policy/procedures manuals, and program objectives
Assist with special projects as assigned
Conduct system and procedural efficiency evaluation to determine progress, performance, and conformance with program requirements
Assist in managing outpatient referrals for PRC
Follow up on outside inpatient referrals for continued follow up, e.g., appointments and PHN referrals
Provide coverage for inpatient units and Outpatient Clinics; manages care of prioritized TCRHCC/SPHC outpatient/inpatient based on provider recommendations; maintain ongoing consultation with service providers
Work proactively with Utilization Review (UR), Public Health Nursing (PHN), Patient Benefit Coordinators (PBC), and PRC at TCRHCC/SPHC
Facilitate communication and coordination among health care team members, involving the client in decision-making to minimize service fragmentation
Develop a care and service delivery plan with patient/family and multidisciplinary team, and provide ongoing case consultation with all direct service providers
Provide service monitors and follow-up to ensure continuity of care; promote client self-advocacy and self-determination
Prepare patient and family for termination (discharge) from case management when services are no longer required; arrange ongoing support with discharge planners and other entities
Familiar with Advance Directives; facilitate informed choice, consent, and decision-making
Promote use of evidence-based care and reference guidelines
Pursue professional excellence and maintain competence in practice
Serve as the outpatient/inpatient coordinator with duties including:
Primary contact for outpatient/inpatient bed admissions within and outside of TCRHCC/SPHC
Collaborate with providers and nursing staff to ensure seamless admissions
Ensure admission documentation and referrals for third-party resources are complete before patient departure
Provide coverage in all units for staffing shortages as necessary
Incumbent will be required to take call on scheduled weekends, as necessary
Ensure proper PPE is worn at all times while on duty and donning/doffing tasks are performed safely
Complete all required cleaning and decontamination tasks for surfaces contaminated by a communicable disease
Performs other duties as assigned
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Incumbent serves as Lead Social Worker/Registered Nurse (RN) Case Manager for TCRHCC and Sacred Peaks Healthcare Center (SPHC) and is responsible for direct supervision and supportive contact for the specific group of identified high-risk patients. The Lead Social Worker/RN Case Manager assists the Director of Care Coordination with management of the MSW and Case Managers with onboarding program, day-to-day assignments, routine reporting, and supervisory duties. Designs and manages a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency. Responsibilities include assessment, service planning, and resource acquisition, monitoring progress, and initiating and responding to emerging client needs. The Lead Social Worker/RN Case Manager links clients with Community Social Service providers, health care providers, substance abuse, and mental health providers to achieve goals. This role works with culturally diverse low-income populations facing barriers such as illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. The Lead Social Worker/RN Case Manager works with a multidisciplinary team and may have assignments related to Purchased and Referred Care (PRC), providing assistance to the PRC Case Specialist. This role reports to the Director of Case Care Coordination.
Qualifications NECESSARY QUALIFICATIONS
Education:
MSW Social Worker: Master’s Degree in Social Work (MSW), OR
RN Case Manager:
Associates degree in Nursing
License/Certification:
Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association throughout employment
MSW Social Worker:
Licensed Master Social Worker (LMSW) OR
RN Case Manager:
A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
Experience:
Must have a minimum of three (3) years of experience in the clinical care setting or with case management.
Demonstrate knowledge of electronic health record systems.
Other Skills and Abilities:
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each of the following areas:
Positive working relationships with others
Possession of high ethical standards and no history of complaints
Reliable and dependable; reports to work as scheduled without excessive absences
Effective verbal & written communication skills
Team management focus promoting a positive and proactive approach to problem resolution
TCRHCC confirms the applicant can perform the essential functions of the job
Successful completion of and positive results from all background and reference checks, including fingerprint clearance requirements, physical examinations, and other screenings indicating qualification to be employed by TCRHCC
Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information
MENTAL AND PHYSICAL EFFORT Physical:
This position requires an individual of high energy who can maintain a long and flexible schedule. Physical requirements include sitting for long periods, frequent walking, occasional driving, climbing, bending, kneeling, crouching, twisting, balance, and reaching. Ability to hear, speak, and understand others; lift up to 35 lbs; push/pull up to 10 lbs; and vision requirements including color and depth perception. Keyboard use and fine motor manipulation are required.
Mental:
Uses independent judgment and analytical skills to make decisions impacting operations, finances, and customer service. Ability to work in structured and unstructured environments, maintain attention to detail, handle multiple priorities in stressful situations, and manage shift work. Must cope with high levels of stress and communicate calmly in challenging situations.
Environmental:
May be exposed to chemical agents, extreme temperatures and humidity, infectious diseases, dust, fumes, hazardous equipment, and loud noises.
ESSENTIAL FUNCTIONS
Responsible for assisting the Director of Care Coordination, managing the MSW and Case Managers with onboarding program, day-to-day assignments, routine reporting, and supervision of staff.
Coordination of service-specific assessments, service planning and enrollment
Works with all facets of the Case Management continuum, including social support, alternate resources, community referrals, discharge planning, Nursing Home/Skilled Nursing Placement and resource utilization.
Comprehensive and client-centered service planning and coordination
Work proactively with the established RN Case Managers/Social Workers of TCRHCC as a team member for care coordination of the patient populations served by TCRHCC
Resource acquisition, facilitate referrals and connect clients to those resources and referrals
Consistent and ongoing case consultation with all direct service providers
Develop and maintain internal and external resource relationships
Responsible for service monitoring and following up to ensure continuity of care and updating the client service plan
Identify patient needs through consultation and high-risk diagnoses, e.g., COPD, CHF, DM
Assist with the development of department reports, policy/procedures manuals, and program objectives
Assist with special projects as assigned
Conduct system and procedural efficiency evaluation to determine progress, performance, and conformance with program requirements
Assist in managing outpatient referrals for PRC
Follow up on outside inpatient referrals for continued follow up, e.g., appointments and PHN referrals
Provide coverage for inpatient units and Outpatient Clinics; manages care of prioritized TCRHCC/SPHC outpatient/inpatient based on provider recommendations; maintain ongoing consultation with service providers
Work proactively with Utilization Review (UR), Public Health Nursing (PHN), Patient Benefit Coordinators (PBC), and PRC at TCRHCC/SPHC
Facilitate communication and coordination among health care team members, involving the client in decision-making to minimize service fragmentation
Develop a care and service delivery plan with patient/family and multidisciplinary team, and provide ongoing case consultation with all direct service providers
Provide service monitors and follow-up to ensure continuity of care; promote client self-advocacy and self-determination
Prepare patient and family for termination (discharge) from case management when services are no longer required; arrange ongoing support with discharge planners and other entities
Familiar with Advance Directives; facilitate informed choice, consent, and decision-making
Promote use of evidence-based care and reference guidelines
Pursue professional excellence and maintain competence in practice
Serve as the outpatient/inpatient coordinator with duties including:
Primary contact for outpatient/inpatient bed admissions within and outside of TCRHCC/SPHC
Collaborate with providers and nursing staff to ensure seamless admissions
Ensure admission documentation and referrals for third-party resources are complete before patient departure
Provide coverage in all units for staffing shortages as necessary
Incumbent will be required to take call on scheduled weekends, as necessary
Ensure proper PPE is worn at all times while on duty and donning/doffing tasks are performed safely
Complete all required cleaning and decontamination tasks for surfaces contaminated by a communicable disease
Performs other duties as assigned
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