Description

Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

Summary:
The purpose of this position is to work in collaboration with the multidisciplinary team to assist in the selection of appropriate candidates for transplantation, provide ongoing support and expertise through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs. The overall goal of the position is to enhance the quality of patient management and satisfaction, to aid transplant candidates in achieving a positive outcome by attending to their psychosocial needs, to promote continuity of care and cost effectiveness through the integrating and functions of case management, utilization review and management and discharge planning. The person in this key position ensures that the patients care progression path from pre-transplant to post-transplant is quality driven, efficient and effective.

Responsibilities:
1. Screening and Assessment for Transplant- Completes Social Work assessment according to Transplant department guidelines. Gathers relevant, comprehensive information and data through interviews with the patient/family, physician, and other members of the multidisciplinary team. Proactively identifies patients/families with complex psychosocial/discharge planning needs. Assesses understanding of the risks and benefits of transplantation/VAD and/or living donation as appropriate. Assesses patients’ ability to adhere to therapeutic regimens. Assesses patients’ mental health history, including degree of substance and alcohol use and how it may impact the success or failure of organ transplantation, VAD implantation, or the donor’s mental health post-transplant. Assesses patients’ and living donor’s (if applicable) coping abilities and strategies. Assesses patients’ financial capabilities and resources, including who will pay for post-discharge medical care for the donor, if necessary. Assesses provision of adequate social, personal, housing and environmental support. Plans, organizes, develops care alternatives, facilitates, and monitors implementation of care plan, resources available locally, in hospital, in community, and assists with discharge teaching about community support groups in collaboration with the multidisciplinary team and in accordance with the patients’ clinical course and continuing care needs. Attends multidisciplinary rounds, listing conferences and Local Quality Council meetings. Screening and Assessment for Case Management- Screens and assesses for case management utilizing established case department triggers and department guidelines. Completes assessment according to CCM and hospital guidelines. Gathers relevant, comprehensive information and data through interviews with the patient/family, physician, and other members of the multidisciplinary team. Proactively identifies patients/families with complex psychosocial/discharge planning needs.
2. Education- Educates the patient and family about the transplant pre, peri and post process, such as financial responsibilities, required support systems, local housing options as needed, and community services including community support groups, vocational rehabilitation etc.
3. Planning- Assists in developing a patient specific plan to help ensure a successful transplant experience. Plans, organizes, develops care alternatives, facilitates, and monitors implementation of discharge plan and discharge teaching; updates plan of care and discharge plan in collaboration with the multidisciplinary team in accordance with patient clinical course and continuing care needs to expedite post discharge care. Coordinates plan of care with multidisciplinary team to facilitate appropriate progression of care; and to ensure that critical elements have been communicated to the patient/family and all members of the team through patient care conferences and discharge planning activities.
4. Care Coordination- Participates in daily discharge rounds with physician and the multidisciplinary team. Escalates to the appropriate member of the leadership team, clinical practice issues resulting in barriers to discharge. Communicates with the Utilization Manager to maintain up to date information about patient level of care status and to manage level of care transitions and discharge plans. Prioritizes observation patient care needs to assure timely progression of care. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors, and resource center.
5. Intervention- Maintains and assures adherence to applicable clinical pathways or standard practices, tools, and protocols to improve patient outcomes, care progression and reduce LOS and resource consumption. Initiates and facilitates referrals through the support center for home health, hospice, DME, SNF, and rehab. Understands the intricacies of and can interpret with state, local, and federal agencies to optimize placement of patients in the most appropriate setting. Aligns needs of patients with quality, cost effective placement options; such as return to extended care facilities, SNF, or reintegration into the home/community for patients of all ages. Initiates appropriate multidisciplinary consults per CCM guidelines.
6. Communication, Collaboration, Critical Thinking- Effectively communicates (verbal and written) with patient, family, multidisciplinary team, and third party payor regarding treatment goals, care coordination, and discharge planning needs. Collaborates with peers and multidisciplinary team members to assure effective outcomes. Works with team to create solutions and take corrective actions to address issues resulting in variances in the plan of care. Documents all work in EPIC, TransChart, Canopy and other clinical information systems in a timely manner per department guidelines. Collects and enters avoidable days and patient alerts in Canopy. Consistently utilizes critical thinking skills in all aspects of work. Evaluates and modifies case management plan to meet changing needs of patient/family.
7. Outcomes and Continuous Quality improvement- Participates in ongoing process improvements, attends transplant local quality councils. Assists with monitoring appropriate outcome metrics such as length of stay, readmissions, and avoidable days. Proactively develops strategies to improve outcomes related to pathway development, and educational programs.
8. Regulatory Compliance- Remains knowledgeable of and adheres to regulatory requirements for the role of transplant case manager/social worker as stated by all regulatory bodies including UNOS, CMS, and TJC.
9. Professional Development- Maintains competency in field by attending local and/or national educational opportunities. Maintains ongoing knowledge of available social services, including services for death, dying, bereavement, and crisis intervention. Certification to be achieved within three years of hire and maintained throughout employment. Develop continuing education plan in collaboration with continuing education coordinator.

Other Information

Job Details

Legal Employer: STATE

Entity: UNC Medical Center

Organization Unit: Kidney Pre Transplant Program

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Schedule: Day Job

Location of Job: US:NC:Chapel Hill

Exempt From Overtime: Exempt: Yes

Work Assignment Type: Hybrid

Salary Range: $32.23-$46.33 (Hiring Range)

Pay offers are determined by experience and internal equity

Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.