Job Summary: Responsible for acute care sites of service to assess, plan, facilitate, and integrate coordinated care for patients from preadmission/ED through discharge with a plan of care that supports post discharge care needs across the continuum. Addresses barriers, social determinants of health, high utilizers of sites of service, supports and integrates psychosocial and legal components that impact the patient and the plan of care. Coordination of post discharge services including but not limited to when applicable per patient needs: placement, durable medical equipment, home health, personal care services, and other complex care support needs. Consults with the multi-disciplinary teams, committees, Service Lines, Providers, and the patient/family. Compliant with state, federal, hospital and TJC guidelines. Follow the standard work for the Case Management department which includes but not limited to discharge planning starts on admission, timely documentation, education on patient plan of care, reporting to Adult Protective Services (APS)/Child Protective Services (CPS), required documentation to support discharge planning functions, resource identification, and other duties as assigned.Qualifications: BSW - Bachelor’s degree in Social Work or related field from a recognized college or university required. At least 1 year social work experience required. Experience in case management, home health, quality and/or utilization management, community or hospital setting preferred. Thorough knowledge of general nursing/social work principles, methods, techniques, community resources, discharge planning processes, and State/Federal laws as they relate to Case Managers role. Exemplary verbal and written communication, critical thinking, interpersonal/group/leadership negotiation skills, and detail-oriented focus. Ability to communicate well with patients, family, staff, providers, service lines, and community resources to promote positive outcomes. Proficient in computer skills and MS Office software. BLS preferred for hire but required completion within 3 months of hire date.MSW - Master's degree in Social Work or related field from a recognized college or university required. At least 1 year social work experience required. Experience in case management, home health, quality and/or utilization management, community or hospital setting preferred. Thorough knowledge of general nursing/social work principles, methods, techniques, community resources, discharge planning processes, and State/Federal laws as they relate to Case Managers role. Exemplary verbal and written communication, critical thinking, interpersonal/group/leadership negotiation skills, and detail-oriented focus. Ability to communicate well with patients, family, staff, providers, service lines, and community resources to promote positive outcomes. Proficient in computer skills and MS Office software. BLS preferred for hire but required completion within 3 months of hire date.RN - Associates degree in Nursing from a recognized college or university required; advanced degree preferred BSN/MSN. Certification in Case Management preferred. Two+ years nursing experience. Experience in case management, home health, quality and/or utilization management, community or hospital setting preferred. Thorough knowledge of general nursing/social work principles, methods, techniques, community resources, discharge planning processes, and State/Federal laws as they relate to Case Managers role. Exemplary verbal and written communication, critical thinking, interpersonal/group/leadership negotiation skills, and detail-oriented focus. Ability to communicate well with patients, family, staff, providers, service lines, and community resources to promote positive outcomes. Proficient in computer skills and MS Office software. BLS preferred for hire but required completion within 3 months of hire date.EOE AA M/F/Vet/Disability
