Senior Social Worker Case Manager

Summary

The Social Worker Case Manager II, as a key member of the Care Management team, is responsible for coordinating patient care across the continuum. This role integrates clinical social work expertise with knowledge of post-acute care needs, behavioral health, and community resources to ensure safe, timely, and cost-effective transitions of care. The Social Worker Case Manager applies principles of discharge planning, quality management, and resource utilization while collaborating with the multidisciplinary team to achieve optimal patient outcomes.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned. Demonstrates the knowledge base and essential skills required to effectively carry out the job.

1. Demonstrates the ability to interpret, analyze, and apply relevant psychosocial and clinical data to prioritize and determine a course of action appropriate to meet the patients’ management needs.

2. Demonstrates effective communication and collaboration with culturally and professionally appropriate interpersonal skills.

3. Demonstrates effective time management and the initiative to carry out job responsibilities in a timely manner.

4. Effectively assesses, plans, implements, and evaluates strategies that ensure the appropriate utilization of community and psychosocial resources and management of length of stay.

5. Effectively assesses, plans, implements, and evaluates the effectiveness of the discharge plan for the assigned caseload of patients.

6. Meets all organizational requirements. Demonstrates initiative to establish and achieve personal and professional goals.

7. Demonstrates effective customer service behaviors as defined by the organization’s mission, vision, and values.

8. Creates and implements a discharge plan for every admitted patient. Assesses each patient’s psychosocial, functional, legal/financial, and safety status, including self-care and environmental factors.

9. Develops a discharge plan tailored to the patient’s needs and problems. Collaborates with physicians, nurses, and other ancillary staff, multidisciplinary team members, and community resources to make recommendations for effective, appropriate patient management.

10. Comanage patient caseloads on a continuous basis in partnership with RN Case Managers.

11. Identifies and addresses patients’ and families’ needs related to social determinants of health (SDOH), and refers to appropriate resources such as community agencies, private caregivers, behavioral health and psychosocial services, transportation assistance, medical and housing support, and educational materials.

12. Implements the discharge plan and referrals to services. Identifies and resolves delays and obstacles to discharge. Acts as a key leader and advocate in the discharge planning process.

13. Monitors patient length of stay and utilization of resources on an ongoing basis. Identifies avoidable days and opportunities for process improvement and recommends actions to optimize efficiency and resource use.

14. Communicates following the chain of command regarding proper utilization of resources, psychosocial concerns, and discharge barriers.

15. Provides information as required regarding denials/approvals. Collaborates with physicians, RN Case Managers, and insurance companies to support post-acute activities.

16. Communicates denials to patients, families, and physicians as needed, specific to post-acute services.

17. On a concurrent basis, enters all pertinent data (discharge plan) in data collection systems as per policy/established process.

18. Participates in clinical performance improvement activities as needed and as assigned. Completes readmission interviews with patients/families to help determine psychosocial causes of readmission. Enters information into appropriate systems.

19. Understands the intricacies and can interpret/negotiate with state, local, and federal agencies to optimize placement of patients in the most appropriate setting. Assesses and aligns the needs of patients with placement options that are consistent with the desired level of care.

20. Works within the CMSA Standards of Practice and adheres to the NASW Code of Ethics.

21. Serves on committees to promote advancement of organizational and departmental operations and practices.

22. Serves as a preceptor for new hires and a mentor for other Case Managers.

23. Other duties as assigned.

24. Employee must be proficient in assigned job responsibilities within 90 days.

Supervisory Responsibilities

Reports To: Director Case Management
Supervises: N/A

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education:
Master of Social Work required

Experience:
Minimum of two (2) years of clinical social work experience with one (1) year of Case Management experience required in acute or post-acute setting such as acute care hospital, post-acute rehabilitation, home health or community nursing setting.

Certificates, Licenses, Registrations

1. Must have active CPR certification and follow hospital policy for renewals; reference the RQI policy.

2. Case Management Certification (ACMA or CCM) required within two (2) years of hire.