The Social Worker Case Manager l evaluates the ability of patients to progress throughout the continuum of care. Works collaboratively in communication with physicians, nursing and other members of the multidisciplinary care team to effect timely and appropriate patient management. Showcases a working knowledge in utilization management, managed care and payer issues. Provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting, with an understanding of pre/post-acute resources. Provides coordination of services and acts as a key Liaison between patients, families and the interdisciplinary healthcare members.
Job Responsibilities
- Participates in the assessment of patients' biopsychosocial needs through review of patient information, personal contact with patients/families and interdisciplinary care team members. Communicates routinely with patients, families, interdisciplinary care team members and other appropriate parties with regard to the status of patients' care plans. progress toward treatment goals, identification of concerns and/or problems, problem solving and assisting with conflict resolution when necessary.
- Ensures that all options available to support a successful transition and elements critical to patients' care plans have been communicated to patients/families and members of the healthcare team and are documented as necessary to ensure continuity of care. Refers cases and issues appropriately to resolve barriers to care progression. Acts as an advocate for patients to resolve barriers to care progression.
- On the basis of preliminary risk screenings, assesses the psychosocial risk factors of patients/families through the evaluation of prior functional levels, appropriateness/adequacy of support systems, reactions to illnesses and the ability to cope.
- Intervenes with patients/families regarding emotional, social and financial consequences of illness and/or disability.
- Serves as a resource person and provides counseling and interventions related to treatment and end of life decisions. Advocates for patient/family empowerment and independence to make autonomous healthcare decisions and access needed healthcare services.
- Provides discharge planning and continuity of care for assigned patients in the acute and post-acute settings.
- Initiates and facilitates referrals to clinics, home healthcare, hospice, SNF, acute rehab, LTAC, TCM, medical equipment and supplies as indicated.
- Collaborates with the interdisciplinary care team, patients and families in the assessment/coordination of discharge planning needs, delivery of post-discharge planning needs, delivery of post-discharge services and transition of patients from the hospital to the discharge setting as well as ongoing care in the community.
- Documents relevant discharge planning information in the medical record according to department standards and/or care management plans. Collaborates/communicates with internal/external Case Managers.
- Provides coordination of services and acts as a key Liaison between patients, families and the interdisciplinary healthcare members.
- Performs other duties as assigned.
This position is Wednesday, Thursday and Friday nights from 7pm-7am for Crisis Intervention, Bereavement Support and Discharge Planning.
Requirements:
Masters Degree in Social Work
One – two years of experience in clinical care or clinical case management
Basic Life Support through the American Heart Association upon start
Additional Requirements
We are Inova, Northern Virginia’s leading nonprofit healthcare provider. Every day, our 24,000+ team members provide world-class healthcare to the communities we serve. Our people are the reason we're a national leader in healthcare safety, quality and patient experience. And from best-in-class facilities to professional development opportunities, we support them at every step. At Inova, we're constantly striving to be ever better — to shape a more compassionate future for healthcare.
Inova Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, pregnancy (including childbirth, pregnancy-related conditions and lactation), race, religion, sex, sexual orientation, veteran status, genetic information, or any other characteristics protected by law.
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