Social Worker Case Manager

POSITION PURPOSE 

In collaboration with the care team helps facilitate and collaborate services for patient while in the hospital. The social worker assesses for and links patients and their families to resources, provides psychosocial assessment and support.  

ESSENTIAL FUNCTIONS 

Knows, understands, incorporates and demonstrates the mission, vision and values of Trinity Health in leadership, behaviors, practices and decisions. 

Establishes partnerships with Patient Experience champions to align efforts with patient satisfaction outcomes. 

Supports ministry and system goals for capacity management through achieving length of stay goals, identification of avoidable delays at department approved levels, and other Case Management initiatives. 

Completes comprehensive assessment of patient situations utilizing Case Management documentation standards, review of medical record, collaboration with health care team and discussion with patient/family.   

Analyzes patient and family situations that will require advance advocacy with knowledge of community resources.   

Recognizes problems, systematically gathers data, identifies/understands underlying issues, synthesizes complex issues, seeks input from others and makes difficult decisions to formulate appropriate treatment plans. 

Completes behavioral health/substance use assessments and makes referrals to inpatient and outpatient services as appropriate.   

Addresses issues relating to guardianship, adoption, medical decision making, end of life and complex family systems. 

Collaborates with the multidisciplinary team both internally and externally (i.e., FCCS, APS, clinics, palliative care, hospice agencies, etc.) including physicians and other healthcare disciplines, and outside agencies regarding patient needs, stay management and payment issues.   

Serves as the liaison between the ministry and the Medicare Beneficiary and Family Centered Care Quality Improvement Organization for patient discharge appeals in accordance with Medicare Conditions of Participation and within established timelines. 

Communicates, pertinent information, including psychological and clinical, to appropriate members of the patient care team.  Keeps patient/family, payer/physician apprised and updated.  Communicates specific issues to Case Management Leaders, Medical Advisor and hospital leadership as appropriate, including discharge barriers and delays. 

Reviews patient treatment plan to identify opportunities to facilitate movement through the healthcare continuum, coordinating all aspects of hospitalization and discharge planning and ensuring effective and efficient utilization of resources. 

Documents pertinent assessments, interventions, transitions, and outcomes for patients in accordance with documentation standards, policies, procedures and/or guidelines, as well as patient/family involvement and choice in selection of post-acute care providers and discharge plan.  

Maintains expertise in behavioral health psychosocial assessment, crisis intervention and brief treatment counseling techniques if applicable. Maintains professional development and licensure. 

Incorporates age and development needs of the patient population into the discharge plan. 

Applies knowledge of local, state, and federal programs to expedite discharge while being a good steward of healthcare resources. 

Establishes and maintains positive working relationship with physicians, nurses, and other members of the interprofessional team. 

Advocates for patient legal, social, and ethical rights while balancing patient resources and hospital financial stewardship.  Refers ethical, quality and risk management issues to appropriate source. 

Attends and participates in care management team meetings.  Participates in projects and committees as requested.  Provides orientation/training of other Social Workers as requested. 

Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health Integrity and Compliance Program and Code of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior. 

MINIMUM QUALIFICATIONS 

Master’s degree in social work.   

License in the State where licensure is required. 

At least two (2) years of recent acute care hospital-based experience. 

A personal presence which is characterized by a sense of honesty, integrity, and caring with ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health. 

Exceptional interpersonal and relationship building skills required to effectively collaborate with multiple stakeholders to obtain management, colleague, and physician involvement and accountability in achieving specific outcomes. 

Ability to simultaneously address and prioritize multiple projects, demands and issues. 

Must possess excellent verbal and written communication skills, presentation skills, advanced analytical skills, be well organized, and maintain a highly professional manner and appearance. 

Demonstrated ability to operate in a collaborative, shared leadership environment. 

Demonstrated high degree of self-motivation, assertiveness, and goal-attaining capabilities. 

Effective negotiation, persuasive, business planning and verbal/written communication skills. 

Ability to be flexible and adaptable to changing processes and schedule requirements. 

Demonstrated ability to acknowledge and analyze formal and informal assessments of health care market trends, locally and across the country, and the impact/potential impact on the organization. 

Possesses knowledge of budget processes, quality improvement, report distribution, The Joint Commission standards, state, and federal regulations, six sigma and LEAN methodologies. 

Proficient in common software applications and electronic medical records. (Word, Excel, Power point). 

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS 

Ability to walk and stand continuously at least 90% of the time. 

Must be able to set and organize own work priorities and adapt to them as they change frequently.  Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.  

Working weekend, holiday, and rotating shifts as well as on-call is required. 

Must possess the ability to comply with Trinity Health policies and procedures. 

Communicates frequently, in person, via telephone, email, fax, etc. with people 

Manual dexterity is needed to operate a keyboard.  Hearing is needed for extensive telephone and in person communication.