PRN Social Work Case Manager - Ambulatory

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Position Title PRN Social Work Case Manager - Ambulatory Sudler Position Summary / Career Interest: The Social Work Case Manager, under the direction of the Social Work Manager and Nurse Manager in Case Management, has responsibility to provide care/service safely and efficiently for a full range of services to patients of all ages and their families. Primary role is to collaborate, communicate and facilitate coordination of services post-hospitalization as established by the healthcare team and executed by the case manager. Responsible for the psycho-social assessment of patients, for post hospital discharge needs including home care, nursing home placement, durable medical equipment, financial assistance, counseling, and other community resources. Ensure appropriate decision makers are informed of and involved in treatment planning. The Social Work Case Manager identifies, monitors, and reports opportunities for quality and performance improvement to the appropriate department. The Social Work Case Manager takes an active role in performance improvement activities as it relates to their area of assignment. Responsibilities and Essential Job Functions Accepts responsibility and accountability for achievement of optimal outcomes within their scope of practice. Follows policies, procedures, and standards; complies with Corporate Compliance program. Assumes responsibility for risk and safety issues associated with the position. Takes call as required by the department expectations. Performs job specific responsibilities and demonstrates accountability for own actions and decisions. Acquires and maintains knowledge and competence related to the expectations of their position and practices within their scope. Brings ideas and concerns to supervisor, participates in department decision making. Maintains current licensure. Completes psychosocial assessments of patient/family situations including social, psychological, emotional, financial and other related factors to facilitate patients return to the community. Identifies and utilizes all relevant information (medical/nursing needs, social work knowledge base, disease process, knowledge of community resources) to accurately and thoroughly assess the patient's psychosocial situation. Evaluates psychosocial and medical/nursing information to determine an appropriate social service action/discharge plan. Utilizes social work assessment and input from other team members to formulate realistic recommendations for social work action plan/discharge plan. Participates in interdisciplinary team meetings as needed. Initiates and participates in family conference to determine psychosocial and discharge planning needs. Facilitates and participates in daily Interdisciplinary Care Coordination (ICC) Huddles by managing the daily meeting and providing relevant and discipline specific information to the entire healthcare team. Advocates on behalf of patients and caregivers for identification and access to services. Advocates for the protection of the patient's health, safety and rights. Ensures patient choice and consistently supports a patient centered environment. Provides supportive counseling to assist patients/families in adjusting to disability and illness, and for realistic planning for post hospital care. Demonstrates a caring, positive regard for others by clarity of speech, use of understandable terminology and utilizing active listening skills. Assures prudent utilization of all resources (fiscal, staff resources, environmental, equipment and services) by evaluating the options available. Demonstrates ability to balance cost and quality to assure the optimal clinical and financial outcomes. Documents appropriate information in the patient's medical record to ensure communication of patients' psychosocial needs for post hospital care. Documentation includes: initial contact note and follow-up action plan, psychosocial assessment of patient/family including previous living situations, daily telephone calls and meetings with significant others and allied professionals, all family and/or discharge planning conferences and response to orders within 24 working hours. Contributes to the financial viability of hospitals. Works in partnership with RN Case Manager to insure timely patient discharge. Utilizes established procedures and appropriate resources in working with third party payors to ensure safe and timely discharge. Participates in the case management activities at assigned site/service. Participates in professional development activities. Attends workshops, conferences or seminars suggested by Manager. Completed the objectives identified on last performance appraisal. Identifies professional development needs and pursues educational opportunities. Participates on hospital task forces and committees. Attends and participates in department meetings. Acts as a preceptor for new team members. Assists in training of new team members. Seeks clinical supervision when