Position Summary:
We have an exciting opportunity to join our team as a Care Manager Social Worker - Full Time, Days - Care Management - Full-Time - Monday - Friday with Al.

In this role, the successful candidate In collaboration with the Care Manager (CM) and other members of the health care team provides clinical social work services for patients and their families in their assigned case load. Responsible for psychosocial assessments and discharge planning for patients with complex psychosocial and medical problems. Assists patients and their families in coping with difficulties related to hospital admission, illness, treatment, and discharge. Provides assessment, planning, intervention, and evaluation of patient/family needs throughout the hospital stay. Has an integral role on the interdisciplinary team to effectively ensure optimal patient outcomes and length of stay efficiency.

Job Responsibilities:

Discharge Planning

• Identifies patients in assigned caseload with complex social and medical issues through case finding and referral process.
• Collaborates with the CM to implement discharge planning activities for complex patients in order to ensure a timely discharge and provide appropriate linkage with post hospital care providers.
• Assess patients and families psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness, and ability to cope.
• In collaboration with the CM participates in daily and weekly care progression rounds case presentation and follow up to facilitate discharge.
• Identifies need for patient care conferences to resolve barriers in care progression and takes a lead role in organizing them.
• Screens for financial needs and refers to appropriate personnel and/or programs and communicates reimbursement information to patients and families in collaboration with responsible CM.
• Communicates and coordinates findings and care recommendations effectively and collaboratively between disciplines to achieve targeted outcomes.
• Documents relevant information in the medical record according to department standards.
• Seeks guidance from CM Manager/Director as needed to manage complex cases and resolve problems.
• Escalates cases with barriers to discharge when unable to resolve issues, according to department procedure.
• Maintains current knowledge of payor reimbursement requirements for post hospital services.
• Maintains a working knowledge of available community resources by establishing a relationship with liaisons and admissions staff at agencies and facilities in the region

Crisis Intervention/Counseling

• Performs assessment for cases of suspected elder, child, or domestic abuse.
• Complies with required reporting, according to state law and hospital policy.
• Utilizes crisis intervention skills to assist victims/families of child abuse, elder abuse, domestic violence, sexual/criminal assault and traumatic injury.
• Refers patients/families to appropriate community agencies for further intervention or counseling services as needed.
• Documents all pertinent information in the medical record.
• Communicates with the health care team to facilitate the progression of care.

Patient Rights/Ethics

• Demonstrates knowledge of Advance Directives and patient rights.
• Assists care team in identifying the appropriate decision maker for the patient when the patient lacks decisional capacity.
• Has knowledge of guardianship process and intervenes to assist the clinical team when the need arises.
• Has the ability to counsel/educate patients/families regarding patient rights, decision making and formulating Advance Directives.
• Facilitates family meetings when there is disagreement or lack of clarity around goals of care and plan of care.
• Collaborates with the health care team to help resolve family conflict around care decisions.
• Provides support to patient and family to help facilitate the decision making process.
• Communicates and coordinates findings and recommendations effectively and collaboratively between disciplines to achieve patient focused outcomes.
• Demonstrates knowledge of options for care for patients with life limiting illness.
• Links patient and families to available resources in hospital and community to provide ongoing support such as Palliative Care and Hospice.

Minimum Qualifications:
To qualify you must have a Masters degree in Social work with a current NY state license.
Two years recent experience in a medical setting preferred.
Knowledge of social work policies, procedures, and state and local regulations.
Knowledge of community resources, third party payors and reviewing agencies.
Highly developed verbal and written communication skills.
Good organizational skills, ability to prioritize with many competing time demands.
Ability to communicate/collaborate with team members, payors and community agencies while maintaining and promoting positive relationships, using diplomacy, tact, assertion and compassion.
Advanced problem solving skills necessary to manage complex situations.
Computer skills: Proficiency with typing, Microsoft office primarily word and email..

Required Licenses: Licensed Social Worker - NYS