Social Worker Case Manager Outpatient Behavioral Health

null

• Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate.
• Assesses patients and families wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.
• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Provides patient and family advocacy, and support patients choice and patient rights during hospitalization.
• Communicates with Payors patients needs for authorization for post-acute care as needed.
• Assesses readmitted patients for the patients and familys perceived reasons for the readmission.

• Master's Required
• Four or more years of Work Experience Required
• Experience with behavioral health patients of all ages preferred
• Bilingual English/Spanish preferred
• 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 records
• 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
• Leadership skills
• Data analysis skills
• Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement
• Knowledge of state and federal guidelines pertinent to Care Management
• Ability to identify appropriate community resources and to work collaboratively with patients, families, multidisciplinary team and community agencies to achieve desired patient outcomes

• Medical, Dental, Vision Insurance
• Life Insurance
• Disability Insurance
• Paid Time Off
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Whole Person Well-being Resources
• Mental Health Resources and Support

null