**This position is open to Internal candidates only**
This position is a 20 hr/wk, Day shift position, scheduled for Friday, Sunday, every other Monday.
The Care Manager/Medical Social Worker is responsible for identifying medically and psychosocially complex patients and families who are likely to benefit from care management and meet high risk criteria and for the coordination of care for these patients. This includes: collaborating with individuals and their families using the care management process for assessing needs, developing plan of care, coordinating delivery of services, monitoring changes, and reassessing the person¡¿s needs on a regular bases; working collaboratively in a shared leadership model with the RN Care Coordinator; working collaboratively across
departments within the acute care setting and with community agencies and providers across the continuum of care; facilitating the coordinated utilization of resources for maximization of health outcomes, patient/family satisfaction and financial outcomes.
ESSENTIAL FUNCTIONS Screen and identify patients who need care management per high risk criteria. Asses, develop, implement and monitor a comprehensive plan of care through an interdisciplinary team process in conjunction with the patient and family in internal and external settings. Collaborate with the multi-disciplinary team to identify problems or needs that require special planning, intervention, teaching or follow-up. Identify key problems, strengths and resources to be addressed in the plan of care why may include: over or under utilization of services; premature discharge from an appropriate level of care; need for specific service to improve health status; caregiver fatigue and burden; knowledge deficits,; inability to comply with plan of treatment; counseling or support needed to cope with situation; and inability to access appropriate level of care due to lack of financial resources or lack of available service. Actively support measures that promote effective use of resources. Identify, plan and arrange for appropriate services applying a knowledge of services available in the community, state, and federal health regulations and admission, discharge and medical necessity criteria. Ensure effective planning and arranging for needed services upon discharge. Intervene by arranging services, education and providing psychosocial support to prepare the patient and their family to manage their healthcare needs within the acute care setting and post discharge. Educate the patient and family about appropriate self-care and management of their health contrition. Coordinate with the Interdisciplinary Team and community resources when appropriate, regarding the multiple details of transitional care management plan. Consult with physician and interpret access, continuity, coordination and home care needs of patient. Inform providers and payers of patient status and service needs; consult with them on modification of care plan and financial arrangements. Monitor the individual's condition and responsiveness to their interventions. Evaluation: this includes appropriate documentation; evaluating patient's response to plan of care and appropriateness of services; evaluating the effectiveness of the care management service and services provided; collaborating with team members to identify cause and adjust plan if patient's health status is not improving; perform Clinical Pathway variance identification, analysis and management of resolution; conducts post discharge follow-up calls.
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EDUCATION: Masters degree in social work (MSW) is required. In lieu of an MSW, the following qualifications and experience may be accepted:
1) Masters degree in counseling or related filed with a minimum of two years work experience in a medical or healthcare setting, social service agency, or community organization focusing on health and/or welfare issues.
2) BSW degree plus four years employment as a medical social worker in a hospital setting.
EXPERIENCE/TRAINING: A minimum of two years employment in a healthcare setting or community agency dealing with health and/or welfare issues Demonstrated knowledge of community health, welfare and social agencies required Demonstrated knowledge of and ability to apply age specific principles of growth and development and life stages to meet each patient's needs Demonstrated proficiency in social work practice.
OREGON: Licensed Clinical Social Worker preferred.
Certification in Case Management highly desired.
PeaceHealth - 14 months ago
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