SW Case Manager MSW

Summary

The Social Worker Senior Case Manager (LMSW), 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 LMSW 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 daily; other tasks may be assigned.

General Responsibilities

1. Demonstrates the knowledge base and essential skills required to effectively carry out the job.

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

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

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

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

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

7. Meets all organizational requirements and demonstrates initiative to establish and achieve personal and professional goals.

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

Case Management and Discharge Planning

1. 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.

2. Develops discharge plans tailored to patients' needs and problems. Collaborates with physicians, nurses, and other multidisciplinary team members to make recommendations for effective, appropriate patient management.

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

4. 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.

5. Implements discharge plans and referrals to services. Identifies and resolves delays and obstacles to discharge, serving as a key leader and advocate in the discharge process.

6. 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.

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

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

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

10. On a concurrent basis, enters all pertinent data (discharge plans) in data collection systems per policy and established process.

Quality, Compliance, and Performance Improvement

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

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

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

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

Leadership and Professional Development

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

2. Attends educational trainings and reports back to the department on best practices and key takeaways.

3. Works alongside the Lead Trainer Case Manager to serve as a primary preceptor for new hires and a mentor for other Case Managers.

4. Owns a departmental project that drives measurable outcomes and results for the department and organization.

Emergency Department Gatekeeper Responsibilities (as assigned)

1. May serve as the Emergency Department (ED) Gatekeeper Social Worker Case Manager as assigned, supporting appropriate patient placement, admission necessity, and transitions of care in accordance with ACMA and NASW standards and hospital utilization policies.

2. When functioning in the ED Gatekeeper role, conducts real-time psychosocial and clinical reviews to determine admission, observation, or outpatient status, escalating complex cases to the physician advisor or leadership as appropriate.

3. Facilitates early identification of psychosocial and discharge needs and barriers, addressing SDOH factors and coordinating with internal and community resources to prevent unnecessary admissions or readmissions.

4. Collaborates with ED physicians, nursing, bed control, and inpatient case management to support hospital throughput, timely disposition, and optimal use of resources.

5. Participates in multidisciplinary huddles and rounds to identify high-risk patients, enhance communication, and promote seamless transitions of care across departments.

6. Other duties as assigned.

Supervisory Responsibilities

Reports to: Director Case Management

Supervises: This job has supervisory responsibilities to social work interns.

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 (MSW)

Experience:
Minimum of three (3) years of clinical social work experience with two (2) years of case management experience required. Must demonstrate strong critical thinking and case management skills. Strong understanding of discharge planning and transitional care principles. Experience with CMS regulations, commercial payer guidelines, and accreditation standards (DNV, TJC). Proficiency in electronic health records (EHR).

Prior leadership, preceptor, or trainer experience preferred.

Certificates, Licenses, Registrations

• Licensed Master Social Worker (LMSW)

• Case Management Certification required through ACMA or CCM

• Obtain CPR certification within 6 months and maintain CPR certification by following hospital policy for renewals reference the RQI policy.