Social Work Care Manager FT Days
Company: AdventHealth DeLand
Posted on: January 12, 2022
Social Work Case Manager Full -Time -Days
Location Address: - -Deland, FL
Top Reasons to Work at AdventHealth
Health Insurance Coverage
Great benefits such as: Educational Reimbursement
Career growth and advancement potential
Low cost of living near sunny beaches
You Will Be Responsible For:
Psychosocial Assessment and Interventions
Assesses patient's and family's psychosocial risk factors through
evaluation of prior functioning levels, appropriateness and
adequacy of support systems, assisting those coping with adjusting
to significant life transitions
Intervenes with patients and families regarding emotional, social,
and financial consequences of illness and/or disability; accesses
and mobilizes family/community resources to meet identified
Serves as a resource to provide information and intervention
related to treatment decisions, terminal illnesses and end-of-life
Provides grief counseling and crisis intervention skills
Advocates for patient and family empowerment and independence to
make autonomous health care decisions and access needed services
within the healthcare system
Provides de-escalation services for patient/family as
Provide Motivational Interview techniques for patients with
substance use and addictive disorders
Provides patient/family education, adjustment-to-illness
counseling, grief counseling and crisis intervention
Provides education to patients/families/caregivers regarding
resource options and coping with diagnosis, treatment and
Works in collaboration with hospital and community agencies to
obtain needed services and resources for
Receives referrals for psychosocial complex needs from the health
Provides assessment and reporting interventions in child
abuse/neglect, domestic violence, adult/elderly abuse, child
protection, sexual assault, and human trafficking as
Provides consult services for patients who may possibly lack
decision making capacity. - Follows the guardianship (temporary/
permanent) policies and procedures and coordinates with Care
Management leadership throughout the process.
Provides consult services for foster care and adoptions.
Assists the health care team in the patient assessments and
placements for mental health services.
Facilitates full team discussion including patient and family when
ethical dilemmas arise.
Promotes the understanding and use of advanced directives and
ensures patient preference and care goals are followed
Completes Initial Evaluation for transition of care needs on all
identified patients within one calendar day of admission and
documents according to policies and procedures. Interviews patient
and involved care givers (as permitted by the patient) as well as a
review of the current and past inpatient and outpatient medical
record in the Initial Evaluation.
Reviews necessary patient information including labs, medications
(Pre and post hospital), History and Physical, therapy notes, ED
notes, test results and progress notes.
Incorporates the patient/family care goals and preferences as much
as possible into the transition of care planning and communicates
these goals and preferences to the multidisciplinary team.
Incorporate clinical, social and financial factors into the
transition of care plan.
Meets with patient/families to discuss realistic and appropriate
discharge options and providers of post-hospital care.
Incorporates social determinants of health into transitions of care
planning and applies risk mitigation interventions to meet the
individual needs of each patient
Identifies and collaborates with the interdisciplinary team and
hospital operations to resolve potential barriers to transition of
care plan achievement.
Collaborates with the multidisciplinary healthcare team daily in
mutlidisciplinary -rounds to efficiently communicate and facilitate
high quality patient progression of care and transitions plans.
Evaluates the potential for readmissions throughout the patient
stay through the monitoring of each patient's readmission risk
scores and coordinating readmission mitigation interventions.
Assures Social Work consults are completed for specialty services
related to psychosocial needs, decision making needs for patients
who lack capacity, patient/family adjustment needs and
psychosocially complex cases.
Develops discharge plan with appropriate contingency plans
throughout the hospital stay to enable adaptation to evolving
patient care needs and ensure timely care coordination.
Escalates issues barriers to appropriate level of Care Management
Assists with End of Life conversation, Living Wills, Advance
Directives, Power of Attorney, Community DNR.
Facilitates patient care conferences with multidisciplinary team as
Establishes and documents, based on the predicted DRG and
multidisciplinary team member's input, Anticipated Date of
Transition (ADOT) and destination and updates, as needed.
Actively participates in daily Multidisciplinary Rounds to review
progression of care and discharge plan for all assigned
Proactively identifies patients who no longer meet medical
necessity and escalates potential denials, documents avoidable
days, and facilitates progression of care.
Collaborates with Utilization Management staff for collaboration on
patient status changes and medical necessity discussions.
Ensures all patients on assigned unit(s) are moved timely and
effectively to appropriate levels of care
Ensures reassessment of discharge needs provided anytime a
patient's condition changes and/or the circumstances impacting the
provision of post-hospital care changes.
Ensures patient notifications are provided and documented in a
timely manner for compliance: - Important Medicare Letters (IML),
Medicare Outpatient Observation Notice (MOON), Patient Choice, and
Beneficiary Notice Letter (BNL).
Communicate with patient/family the possible need to pay for
services out of pocket.
Ensures primary care physician identification and scheduling of
follow-up PCP and specialist appointments for post-hospital follow
Ensures discharge disposition accuracy and consistency in the EMR
on all discharge patients.
Serves as a content expert regarding payor information and educates
interdisciplinary team and patients/caregivers regarding payor
Maintains clinical competency and current knowledge of community
resources, post-acute care providers and payor requirements to
perform job responsibilities.
Participates in department and hospital Performance Improvement
Provides necessary patient care coverage and assistance with other
duties as assigned when needed.
Promotes individual professional growth and development by meeting
requirements for mandatory/continuing education, skills competency,
supports department-based goals which contribute to the success of
Participates in facility and department regulatory and
Social Work Care Manager serves as a preceptor
Social Work Care Manager participates in department education
(bulletin or presentation) with topic and content approved by
Facility CM Director
What you will need:
EDUCATION AND EXPERIENCE REQUIRED:
Bachelor's in Social Work with health care related Masters or
Minimum three (3) years experience in hospital/medical social
EDUCATION AND EXPERIENCE PREFERRED:
Masters in Social Work
Care Management discharge planning experience
Knowledge of state and federal guidelines pertinent to care
KNOWLEDGE AND SKILLS REQUIRED:
Excellent interpersonal communication and negotiation skills
Critical thinking and problem-solving skills
Psychosocial assessment skills
Customer service skills
Ability to work and communicate with people of all social,
economic, and cultural backgrounds; be flexible, open-minded and
adaptable to change
Effective organizational skills
Computer proficiency with Outlook e-mail and electronic medical
Flexible in a complex and changing healthcare environment
Understanding of pre-acute and post-acute venues of care and
post-acute community resources
Maintains a current working knowledge of services available in the
local community, particularly services available to patients with
limited or non-existent payment resources
Strong interview, assessment, and organizational skills
Data analysis skills
This facility is an equal opportunity employer and complies with
federal, state and local anti-discrimination laws, regulations and
Keywords: AdventHealth DeLand, Deltona , Social Work Care Manager FT Days, Executive , Deland, Florida
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