Location:

Bon Secours St Francis Hospital

Shift:

Monday - Friday, Days

Primary Function/General Purpose of Position

Under the general supervision of the Supervisor and/or Manager, and according to established policies and procedures, coordinates, negotiates, and manages the care of patients to facilitate achievement of positive clinical and financial outcomes. Works collaboratively with interdisciplinary staff, internal and external to the organization, to facilitate appropriate delivery of healthcare services. The Case Manager MSW integrates the roles of Case Management and Discharge Planning utilizing a prospective approach for planning the ways in which patient care will be provided, the steps in the care process, and the outcomes of care. This role’s objective is to promote a collaborative interdisciplinary care delivery model to achieve optimal clinical, satisfaction, and financial outcomes. The Case Manager MSW participates in quality improvement and evaluation processes related to management of patient care. Work is of a highly confidential nature.

Essential Job Functions

• ​Performs day to day case management and discharge planning service delivery for patients with complex psychosocial, financial, and legal discharge planning needs aligned with organizational goals for clinical, financial and experience outcomes · Advocates and facilitates patient/family/caregiver centric plans of care based on patient’s needs, preferences and available resources. · Consistently collaborates with multi-disciplinary teams to execute responsibilities including post-acute referrals/discharge planning, crisis intervention, counseling, abuse/neglect, guardianship and psychosocial assessment. · Provides accurate, timely and appropriate documentation of all social work interventions in the medical record per regulatory policies and procedures. · Updates the discharge plan ensuring it is consistent and up to date based on the patients discharge needs, appropriate post-acute level of care, patient/family/caregiver preferences and covered services. · Provides supportive counseling to patients/families about placement options- both for post-acute placements and mental health patients, as appropriate, to include available resources, adoption and guardianship to support a centered realistic discharge plans and realistic expectations. · Ensures mandatory reporting and provision of discharging planning for the patient in cases of suspected abuse or neglect and refers patient cases to the Department of Social Services when applicable. · Collaborates with Financial Services to facilitate obtainment of funding for the acute and post-acute needs.

• Routinely engages in social work and transfer planning systems that support patient transitions of care · Highly visible, on site resource and partner to the hospital and available to discuss and problem solve issues related to the transition plan including barriers to a safe and timely transfer. · Refers and facilitates transfer of patients to appropriate placement options and community resources. · Collaborates with Community resources, such as Access Health/Transition Clinic/CIN/Population Health Team to obtain insurance coverage and access to community resource to ensure proper continuum of care. · Maintains working knowledge of capacity and level of care criteria as it relates to transition of care options.

• Ensures evidence based quality care delivery through communication with the care team, quality outcome reporting and collaboration in process improvement initiatives. · Collects data variances as outlined by department key performance indicators. · Participates in Process Improvement events and collects data related to process improvement initiatives when applicable. · Remains up to date with continuing education related to population served.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.

Licensing/Certification

Currently licensed by the State Board of Social Work Examiners for S.C. required.

Preference will be given to those with Case Management Certification.

Education

Master’s Degree from an accredited school of Social Work required

Work Experience

One year of clinical experience in at least one of the following areas: Case Management, Social Work and/or Discharge planning preferred. Preference will be given to those with hospital experience.

Training

None

Language

None

Patient Population

Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit.

• Demonstrates knowledge of reimbursement systems, the ability to educate patients and families regarding payer requirements / coverage for post-acute care services and the ability to effectively advocate on behalf of the patient to obtain authorizations for continued care as appropriate.

• Maintains working knowledge of post -transition of care options based on facilities capabilities and funding accepted.

• Requires high level negotiation skills and confidence in communicating with and engaging in crucial conversations with physicians and entire healthcare team.

• Requires excellent oral and written communications skills.

• Ability to work in a fast pace team environment.

• Ability to prioritize and multi-task.

• Ability to make sound judgements and act professionally under pressure.

• Ability to maintain confidentiality of sensitive patient information.

• Must have ability to solve problems independently, prioritize work and design creative solutions when resources or options for discharge are limited.

• Maintains a working relationship with external providers, services, agencies to facilitate the transition of care.