Job Summary

Works as part of a dedicated team, the Social Work Case Manager (SW CM) coordinates the care and service of selected patient populations through the acute care episode, across the continuum.

Essential Functions

• Works collaboratively with an RN and interdisciplinary teams, both internal and external to the organization, to improve patient care through effective utilization and monitoring of healthcare resources and assumes a leadership role to achieve desired clinical, financial, and resource outcomes.
• Skills needed include excellent written/verbal communication skills, critical thinking skills, creative problem solving, proficient organization and planning.
• Must be self-directed, and have the ability to tolerate frequent interruptions and a demanding work load. Knowledge of funding, resources, services, clinical standards, and outcomes is preferred.
• Oversees process/procedure of notification for Medicare and Medicare Managed Care beneficiary’s rights per CMS regulations inclusive of but not limited to: Notification of Hospital Discharge Appeal Rights, Condition Code 44, Election of Lifetime Reserve Days, Medicare Outpatient Observation Notice, and Hospital Issued Notice of Non-coverage.
• Assesses for and plans for appropriate discharges.
• Achieves communication and coordination between members of the health care team involving the patient/designee in the decision-making process in order to minimize fragmentation in services.
• Communicates effectively with patients, families, visitors, co-workers, physicians and external providers, treating all with dignity and respect.
• Ability to compassionately perform during a crisis and unpleasant situations.

• Presents to patient and/or designee a list of provider choices for use in transition planning, ensuring that federal regulations are met regarding patient choice and the complete and accurate documentation of such.
• Knowledgeable in assessment and execution of PASSR, EARC PAS criteria.
• Assessment of and assisting families with end-of life issues, holding family meetings, Involvement with Palliative Care Team and Ethics Committee.
• Knowledge of and ability to organize Outpatient Hemodialysis processes.
• Is proactive, with the team, to achieve desired clinical, financial, and resource outcomes. Actively participates in compliance with The Joint Commission standards, processing the AR cycle, fiscal stability and length of stay efforts of the Hospital.
• Respects each patient's right to privacy and confidentiality by complying with HIPAA regulations/law.
• Ability to assess and assist patients with medical, psychological, financial and social needs.
• Advocate for difficult to place patients which include: abandoned elderly, long term ventilator patients, under/uninsured patients, and patients with extensive medical, social and/or psychological needs.
• Facilitates timely and appropriate patient care delivery and hospital resource utilization by performing, among other duties

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Minimum Education/Certifications
Master’s Degree and LSW, MSW, LCSW required

Minimum Work Experience
Five year’s acute care clinical experience preferred.

Position Type/Expected Hours of Work: Five year’s acute care clinical experience preferred.