Clinical Social Worker - Case Management

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 have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

At Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work‑life balance. The available plans and programs include:

• 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, healthcare dependent flexible spending accounts
• Employee assistance program, employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder childcare, auto, home insurance

Note:

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

The Social Worker is responsible for facilitating care along a continuum through effective resource coordination, helping patients achieve optimal health, access to care, and appropriate utilization of resources while balancing the patient’s resources and right to self‑determination. The individual in this position has overall responsibility to assess the patient for transition needs, identify and assess patients at risk for readmission, conduct complex psycho‑social assessment and intervention, and promote timely throughput, safe discharge and prevent avoidable readmissions.

This position integrates national standards for case management scope of services including:

• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by 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

This individual's responsibility will include the following activities: complex psycho‑social transition planning assessment and reassessment and intervention, assistance with adoptions, abuse and neglect cases, care coordination, implementation or oversight of the transition plan, leading and/or 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, ensuring patient education is completed to support post‑acute needs, timely complete and concise documentation in Case Management system, maintenance of accurate patient demographic and insurance information, and other duties as assigned.

• Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients
• Integrates key elements of patient assessment, patient choice, and available resources to develop and implement a successful transition plan
• Completes Complex/Psycho‑social assessment and plan for patients identified as high risk for readmission
• Provides psycho‑social assessment and intervention for patients identified with needs including behavioral health, lack of support systems, financial barriers, end of life, and/or medication adherence
• May delegate the implementation of the transition plan to LVN/LPN or Assistant staff and follows up to ensure the plan is completed timely and accurately
• Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post‑acute providers
• Provides information to patients to make informed choices when community services per Tenet policy
• Completes Final…