About Job

GENERAL SUMMARY: The Case Coordinator – Social Worker evaluates timeliness and appropriateness of patient care, and coordinates discharge planning for a smooth progression to post-hospital care. In addition, the Social Worker might be instructed to provide case review and related recommendations from a social perspective for patients on the Renaissance Unit.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Evaluates timeliness and appropriateness of patient care by reviewing medical record, meeting with physician and other patient care providers, and comparing planned care to hospitalization industry standard criteria adopted by payers.

Identifies delays in progression of patient care related to tests, procedures, or specialty evaluations through ongoing evaluation of the patient and medical record. Negotiates with internal and external providers to promote timely progression of patient plan of care.

Identifies patients with complex discharge planning needs. Recommends options for post hospital care based on required services and available resources. Works collaboratively with physician, patient, other patient care providers, and family members as appropriate to develop discharge plan.

In conjunction with the nurse manager or charge nurse, facilitates multidisciplinary meetings as needed to discuss selected complex and challenging cases, and to develop specialized multidisciplinary plans for post hospital care.

Attends patient multidisciplinary meetings with other health care team members to facilitate the interdisciplinary care of patients and achievement of positive outcomes.

Documents case coordination activities online into Epic Case Coordination activities in CM Flow sheets and utilization activities AUTTH/CERT.

Accepts discharge planning related one-off verbal orders from physicians, reads them back to the physician, documents in the medical record, and communicates to appropriate patient care providers.

Serves as liaison to payers to provide information regarding appropriateness of hospitalization.

Serves as liaison to external providers and payers to arrange for appropriate post hospital services.

Facilitates transfer of information among healthcare professionals to promote smooth patient transition between services and levels of care.

Identifies patients with special age specific needs for protective services court appointed conservator, or child/adult protective services, and makes referral.

Identifies patients with special age specific needs for post hospital care related to decreased independence in the elderly. Recommends appropriate community resources.

Identifies patients with special age specific needs for post hospital care related to home care of a newborn. Recommends appropriate community resources.

Identifies cases with questions regarding medical necessity and appropriateness of hospital services, and makes referral to Physician Advisor member of Clinical Resource Management Committee.

OTHER DUTIES AND RESPONSIBILITIES:

Identifies staff learning needs related to Case Coordination services and conducts formal and informal educational sessions in conjunction with unit manager and staff needs.

Collects data utilizing avoidable day screens, saved day worksheets, and Case Coordination worksheets, to assist with identification of patterns, trends and opportunities for improvement.

Analyzes and interprets data on physician practice patterns, including resource utilization, identifies patterns and trends. Collaborates with physicians to affect a change.

Observes infection control and safety practices.

Performs other duties as required.

PROFESSIONAL RESPONSIBILITIES:

Demonstrates commitment to professional growth through attendance at educational programs within the hospital as well as those offered by accredited organizations.

Maintains active membership in one professional and/or specialty organization.

Participates on appropriate hospital committees and teams.

Actively seeks new methods to improve service in Case Coordination by identifying best practices utilized by other institutions and reviewing current research.

SKILLS AND ABILITIES:

Ability to communicate effectively with patients or residents or their representatives, patient care providers and other health care team members.

Maintains knowledge of local community resources.

Knowledge of age specific characteristics.

Maintains patient confidentiality.

Ability to work flexible hours is required.

Ability to access hospital information system programs.

Ability to move about the hospital as required.

Education and Experience Required:

Licensed to practice as a Social Worker in the District of Columbia. Master’s degree in Social Work or sociology, gerontology, special education, rehabilitation counseling, or psychology from an accredited school.

Minimum of 2-5 years social work experience in a health care setting along with one or more years’ experience Case Coordination performing discharge planning from the inpatient or skilled facility setting and one or more years’ experience conducting inpatient utilization management and case coordination applying industry standard criteria (e.g., InterQual and M&R).

Current CPR Certification required.

Salary Range: Minimum 27.89/hour - Maximum 46.00/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility.

In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority.

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Diversity and Inclusion are Johns Hopkins Medicine Core Values. We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices.

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