The Social Worker or Registered Nurse Care Manager is responsible for coordinating the complex discharge planning needs of patients, as well as to provide supportive counseling, psycho-social assessment, and interventions for designated patient populations across the continuum of care. Also works with the providers, registered nurse care managers, social workers, and multi-disciplinary care teams to facilitate the achievement of desired patient, quality, and financial outcomes.
JOB DUTIES AND RESPONSIBILITIES:
- Develops a discharge plan that addresses the psycho-social needs to meet desired goals for the next step in the continuum of care for patients
- Collaborates with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals.
- Works as a team with other members of care management, including but not limited to: RN care managers, assistants, coordinators, utilization management staff, and director.
- Facilitates communication among all treatment team members.
- Manages length of stay by proactively identifying and mitigating issues and barriers to care and a successful discharge plan.
- Updates the care team, patient/family as to the status of the discharge plans. Re-evaluates and revises the discharge plan as additional information is acquired.
- Proactively considers options such as palliative care, homecare and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of readmissions.
- Issues applicable state/federal regulatory notices as applicable ie.) Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle Payment Care Initiative (BPCI) notification.
- Monitors risk assessment using available tools and implements discharge interventions accordingly.
- Actively addresses and monitors resource utilization and documents delays as appropriate.
- Identifies patients with an unplanned readmission and completes root cause analysis.
- Coordinates utilization of patient and community resources to facilitate achievement of a safe and effective discharge plan and accomplishment of goals as well as minimizing risk of readmission.
- Collaborates with Outpatient Care Managers to identify patients for handover and post discharge follow up.
- Provides supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement. Facilitates the decision-making process in complex cases.
- Facilitates resolution of issues surrounding patient care in a compassionate manner, utilizing team meetings as appropriate.
- Act as resource to the staff for regulatory issues regarding discharge-planning and psychosocial processes.
- Uses electronic systems to accurately document care manager functions.
PHYSICAL AND SENSORY REQUIREMENTS:
Sitting for one to two hours at a time, walk on all surfaces for up to five hours a day, and climb stairs. Must be capable of driving a car and have the ability to finger and handle objects frequently. Occasionally firmly grasp, twist, and turn objects with hands and fingers. May be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Staff must have the ability to hear as it relates to normal conversations and high and low frequencies and to touch as related to telephone and computer keyboard.
EDUCATION:
MSW or equivalent from an accredited school of social work. Current NJ SW license if working at St. Luke’s Warren Campus. May hire per diem BSW’s currently in school within 6 months of completing MSW. If primary coverage area is OB, membership in the National Organization of Perinatal Social Workers is required.
OR:
Graduate of professional nursing program. Registered Nurse with current license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity. NJ RN licensure required for Warren Campus. Advanced degree preferred. BSN required or obtained within 3 years of hire, MSN and/or Case Management Certification preferred.
TRAINING AND EXPERIENCE:
Preference is for at least two years of experience as a Social Worker in an acute hospital setting. Previous care management experience is preferred. Strong critical thinking skills. Ability to maintain collaborative and effective working relationships. Able to assert needs to patients, families, physicians, and other members of the interdisciplinary team while maintaining established rapport and relationships. Knowledge of medical terminology required. Ability to communicate both verbally and in written forms. Basic computer skills required.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
