Clinical Social Worker - Case Management

Job Description - Clinical Social Worker - Case Management )

Clinical Social Worker - Case Management at DMC Sinai‑Grace Hospital.

DMC Sinai‑Grace Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off (PTO)
• Career development and continuing education opportunities
• Health savings accounts, and healthcare/dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits: pet insurance, legal insurance, accident and critical illness insurance, long‑term care, elder care, childcare, auto, home insurance.

Note:

Eligibility for benefits may vary by location and is determined by employment status.

The Social Worker facilitates care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self‑determination. The role includes assessment of transition needs, identification of patients at risk for readmission, and conducting complex psycho‑social assessments and interventions to promote timely throughput, safe discharge, and prevent avoidable readmissions.

Integrate national standards for case management scope of services including:

• Transition Management: promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination: demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
• Compliance: with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education:
  
  provided to physicians, patients, families and caregivers

Additional duties include:

• Psycho‑social transition planning assessment & reassessment, and intervention
• Assistance with adoption, abuse and neglect cases, assessment, intervention and referral as appropriate to local, state and/or federal agencies
• Care coordination and oversight of transition plan implementation
• Leading/facilitating multi‑disciplinary patient care conferences including Complex Case Review
• Making appropriate referrals to other departments
• Communicating with patients and families about the plan of care
• Collaborating with physicians, office staff and ancillary departments
• Assuring patient education is completed to support post‑acute needs
• Timely, complete and concise documentation in the Case Management system
• Maintenance of accurate patient demographic and insurance information
• Other duties as assigned

• Complete comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan.
• Integrate key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan.
• Complete complex/psycho‑social assessment and plan for patients identified as high risk for readmission.
• Provide psycho‑social assessment and intervention for patients identified with needs such as behavioral health, lack of support systems, financial barriers, end‑of‑life, and/or medication adherence.
• May delegate implementation of the transition plan to LVN/LPN or Assistant staff, and follow up to ensure plan completion.
• Ensure all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post‑acute providers.
• Provide information to patients to make informed choices about community services per Tenet policy.
• Complete Final Discharge Disposition Form Assessment for Medicare patients per Tenet policy.
• Complete timely, complete and accurate documentation in the Tenet Case Management system (40% of daily workload, essential).

• Screen patients for factors that may affect the progression of care and intervene as needed.
• Con…