Medical Social Worker, CM, per diem

Job Description:

VALLEY MEDICAL CENTER

Job Description

Case Management

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.

TITLE: Case Manager

JOB OVERVIEW: The Medical Social Worker or Crisis Counselor assesses, coordinates, facilitates, and negotiates services and resources to support coordination and continuity of care in the most appropriate care setting and cost-effective manner for specified populations. This includes collaboration with patients, families, physicians, nurses and other members of the health care team to address patients' medical, disposition, and psychosocial needs through effective coordination of services commensurate with available financial resources and the patient's right to self-determination across the continuum.

AREA OF ASSIGNMENT: Case Management

HOURS OFWORK: Varies

RESPONSIBLE TO: Manager, Case Management

PREREQUISITES:

• A masters level degree in social work (MSW); licensure in the State of Washington (LICSW) preferred, required within 4 years of employment.

• OR, for Crisis Counselor role, in lieu of an MSW, a Licensed Mental Health Counselor or Licensed Marriage and Family Therapist credential based on Washington State Department of Health approved masters-level degree credentialing including a minimum of 2 years post-graduate experience working with crisis intervention services including conducting psychiatric assessments; OR, Mental Health Associate Counselor or Marriage and Family Therapist Associate allowed with licensure in the State of Washington (LMHC or LMFT) required within 3 years of employment.

• Minimum of two-year acute care hospital experience preferred.

• Minimum two years case management experience preferred or equivalent.

QUALIFICATIONS:

• Ability to assess the psychological and social needs of patients in the medical setting; as well as to create, implement, and evaluate the effectiveness of care plans which address identified needs.

• Effective communication skills, including group facilitation and conflict management skills.

• Ability to work in a collaboratively team setting with peers at all times.

• Interpersonal skills necessary to interact with the interdisciplinary teams of care providers, including physicians and nursing staff, to coordinate care for patients and families.

• Sensitivity to coordination of care requirements for all patients and families from a variety of ethnic, cultural, social, and economic backgrounds and with varied medical and developmental needs.

• Knowledge of community resources and how to access them effectively and efficiently.

• Knowledge of the healthcare financial environment, reimbursement, and length of stay management.

• Ability to work independently without close supervision; set priorities, meet outcome expectations and deadlines.

• Ability to function in multiple and varied settings across the facility.

• Ability to set priorities among multiple demands; produce accurate work and meet deadlines.

• Neat and well-groomed appearance consistent with VMC dress code policy.

• Experienced navigator of basic electronic applications including: Outlook, Office, and calendar management.

• Experienced in use of electronic health record (EHR).

• Ability to communicate fluently in English, both verbally and in writing.

• Ability to type fluently and quickly; and write legibly, spell correctly, and use accepted grammar.

UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:

See Generic Job Description for Clinical Partner.

PERFORMANCE RESPONSIBILITIES:

A. Generic Job Functions:See Generic Job Description for Clinical Partner.

B. Essential Responsibilities and Competencies:

• Assess, Plan and Facilitate discharge and transitions of care including the following:

  Review past and present medical records to determine history, admitting diagnosis or procedure, and plan of care compared to previous history and care needs;

  Gather pertinent information about the patient's psychosocial, functional and financial situation to identify needs;

  Meet with patients/caregivers to evaluate clinical, psychosocial, functional and financial status;

  Communicate with the multidisciplinary team (physicians, nurses, therapists, social workers, chaplain, etc.) as needed to complete assessment;

  Establish a discharge plan based upon individual patient needs, patient/care-giver preferences, and existing or proposed treatment options in order to support and promote desired clinical, service and financial outcomes in a timely manner;

  Provide relevant education and information regarding resources to patient/caregiver to facilitate informed decision making and active participation in the plan for transfer/discharge;

  Determine realistic goals with patient/caregiver regarding available options, empowering them to make choices in their best interest;

  Identify benefits and coordinate resources based on patient's needs and preferences;

  Work with insurance companies and/or public health benefit programs (DSHS, Medicare, Medicaid, County, State) to optimize benefits to patient.

• Initiate timely family conferences or multidisciplinary case conferences with the treatment team for complex transition discharges.

• Independently complete assessment and plan interventions sensitive to the patient's cultural, social, physical, mental and economic status and developmental state. Demonstrate sensitivity to the patient's/caregiver's beliefs and values and incorporate that understanding into the discharge plan;

• Manage and prioritize work based on clinical needs, length of stay, required complexity of interventions and acuity of care.

• Document all assessments, plans, and interventions in the medical record with clarity and conciseness unique to each specific patient or family interaction and in accordance with professional, legal, regulatory and departmental standards.

• Perform self-referral screens Monday through Friday, and as appropriate on weekends, per Discharge Planning Review Process, to identify potentially high risk patients who may have an adverse health consequence without a case management order or a discharge plan.

• Communicate effectively with other members of a diverse care team using appropriate interpersonal skills, group facilitation and conflict management skills as appropriate.

• Maintain current knowledge of case management, utilization management, and discharge planning resources.

• Work collaboratively with the Utilization Management team and Patient Financial counselors

• Refer quality, infection control and risk management issues to appropriate individual or department.

• Perform other duties as assigned, including orientation and training of new staff members.

• Serve as committee member or liaison to community partners per request of management.

Specific to Inpatient Medical Social Work:

• Respond to nurse, physician or self-referral screens as soon as possible but not longer than 12 hours or next business day.

• Responsible for assessing and managing the next best site of care; referring to and collaborating with network partners as indicated.

• Demonstrate knowledge of community resources and how to effectively access, develop care plans, and manage transitional care needs to support patient's transition of care, including:

  Crisis intervention

  Homelessness

  Drug and Alcohol, Medication Assisted Treatment

  Home and community services

  Skilled nursing facilities and home health agencies

  Adult Family Home referrals and placement

  Home and Community Services referrals and collaboration

  Shelters

  Opioid treatment networks

  Day health services

  LTACH and Acute Rehab services

• Manage criteria-based social service needs including the following when indicated:

  Complex financial needs

  DAC's screening

  CPS, APS and domestic violence

  Acute mental health needs

  Teen mothers <17 years of age, if indicated

  Homeless or resource poor status

  Bereavement (, terminal care, end of life) if indicated

  Trauma and other special care

  ITA (Involuntary Treatment Act) patients

  Guardianship/conservatorship

  Corrections patients as appropriate

  Advance Directives/Mental Health Directives

• Participate in disposition huddles as scheduled.

• Document updated notes daily or as appropriate containing only new and/or continued relevant content.

• Deliver federally mandated communications meeting timeliness mandates including 2nd Important Message from Medicare, MOON notifications and/or HINN notifications when required.

Specific to ED Medical Social Work:

• Identify patients who are at risk for recurrent visits to the ED. Facilitate a patient-centered approach for use of appropriate community programs.

• Establish relationships in the community and post-acute continuum to support the needs of this population ().

• Contact patients with frequent non-emergent ED visits to establish a plan of care promoting alternative settings. Establish a PCP as indicated. Communicate directly with the patient/family in order to understand and incorporate priorities and acute needs of the patient; educate and prepare the patient/family to make informed decisions.

• Documentation supporting relevant information including patient/family understanding of case management and discharge or admission plan.

• Provide timely communication to ED staff regarding new or updated information involving the coordination of care.

• Data collection as directed by management for process improvement opportunities in the ED setting.

• Support work requirements related to Emergency Department Information Exchange (EDIE) initiative.

Specific to Crisis Counselor:

• Complete assessments, interventions, counseling and completion of plan of care appropriate to the patient's physical, emotional, cognitive and developmental state including the following:

  Evaluate the mental and emotional status of psychiatric patients and facilitate appropriate next steps for care and treatment.

  Screen and refer patients with drug and/or alcohol dependencies to the appropriate level of care.

  Provide support and intervene as legal liaison (when indicated) for patients presenting with physical and/or sexual abuse.

  Provide support and referrals to families and friends of patients in medical trauma.

• Documentation supporting relevant information including outcomes from screening, intervention and treatment; patient/family understanding of plan of care; discharge or admission plan.

• Consults with ED LIP, Hospitalists and psychiatry regarding assessments and appropriate dispositions.

• Provide medication assisted treatment assessments, counseling and referrals per Opioid Treatment Network policy.

Job Qualifications:

PREREQUISITES:

• A masters level degree in social work (MSW); licensure in the State of Washington (LICSW) preferred, required within 4 years of employment.

• OR, for Crisis Counselor role, in lieu of an MSW, a Licensed Mental Health Counselor or Licensed Marriage and Family Therapist credential based on Washington State Department of Health approved masters-level degree credentialing including a minimum of 2 years post-graduate experience working with crisis intervention services including conducting psychiatric assessments; OR, Mental Health Associate Counselor or Marriage and Family Therapist Associate allowed with licensure in the State of Washington (LMHC or LMFT) required within 3 years of employment.

• Minimum of two-year acute care hospital experience preferred.

• Minimum two years case management experience preferred or equivalent.

QUALIFICATIONS:

• Ability to assess the psychological and social needs of patients in the medical setting; as well as to create, implement, and evaluate the effectiveness of care plans which address identified needs.

• Effective communication skills, including group facilitation and conflict management skills.

• Ability to work in a collaboratively team setting with peers at all times.

• Interpersonal skills necessary to interact with the interdisciplinary teams of care providers, including physicians and nursing staff, to coordinate care for patients and families.

• Sensitivity to coordination of care requirements for all patients and families from a variety of ethnic, cultural, social, and economic backgrounds and with varied medical and developmental needs.

• Knowledge of community resources and how to access them effectively and efficiently.

• Knowledge of the healthcare financial environment, reimbursement, and length of stay management.

• Ability to work independently without close supervision; set priorities, meet outcome expectations and deadlines.

• Ability to function in multiple and varied settings across the facility.

• Ability to set priorities among multiple demands; produce accurate work and meet deadlines.

• Neat and well-groomed appearance consistent with VMC dress code policy.

• Experienced navigator of basic electronic applications including: Outlook, Office, and calendar management.

• Experienced in use of electronic health record (EHR).

• Ability to communicate fluently in English, both verbally and in writing.

• Ability to type fluently and quickly; and write legibly, spell correctly, and use accepted grammar.