Under the direction of department leadership, the social service care manager staff provide services consisting of comprehensive case management, care coordination, continuing care services, and clinical social work services including crisis intervention and emotional support within the professional’s defined scope of practice. In addition, the social services care manager is responsible for providing education addressing physical, psychosocial, financial, environmental and other needs of patients and families and/or significant others. The social services care manager is part of an interdisciplinary team who promotes health and address medical and non-medical barriers.

Essential Job Functions

• Coordinates patient needs between support systems, healthcare professionals, community, and state agencies. Serves as a liaison between hospital, clinic, and community agencies to facilitate care coordination and the exchange of clinical and referral information.
• Advocates for and assists the patient as they move across the care continuum.
• Treats all patients with compassion and respects individual rights to self-determination.
• The responsibilities of the Social Worker Care Manager are listed below, in order of priority and intended to ensure effective prioritization of tasks.

Priority 1: Reviews New Patients for Psychosocial Needs

• Reviews Cerner census and ensures all patients are accounted for on assigned floor.
• Meets with unit assigned RN Care Manager at the beginning of every shift to determine patients with complex psychosocial needs.
• Collaborates with RN Care Manager to evaluate patients with psychosocial needs, including but not limited to:
• Psychosocial Assessment
• Crisis intervention/Trauma
• Adjustment to illness/new diagnosis
• Grief & bereavement, end-of-life concerns
• Chronic substance abuse (assessment and referral)
• Abuse and/or neglect (consultation)
• Sexual assault
• Advance Directives
• Self-pay
• Competency concerns
• Homeless/Unsafe discharge
• Guardianship/Adoption
• Mental health/behavioral issues
• Patients admitted from Skilled Nursing Facilities or Alternative Living Facilities
• Pediatrics, Family Birth Center and NICU – and/or baby issues
• Identifies patients and families needing support for emotional, social, and financial consequences of illness and/or disabilities.
• Accesses and mobilizes family and/or community resources.
• Collaborates with the Supportive Care/Palliative Care Team.
• Educates and communicates with the multidisciplinary team regarding identified needs.

Priority 2: Initiates and Coordinates Discharge Planning

• Collaborates with RN Care Managers to resolve complex patient problems.
• Participates in discharge planning activities for complex patients.
• Intervenes with families exhibiting complex dynamics impacting care.
• Communicates discharge planning status to the multidisciplinary team.
• Notifies Care Management Department of newly identified or changed resources.
• Engages patient/family in proactive discharge planning.
• Documents discharge plan and patient understanding, including refusals.
• Educates regarding post-acute options and documents choices per policy.
• Ensures authorization for post-discharge services when required.
• Contacts referral agencies and verifies bed availability.
• Confirms discharge dates and arranges transportation.
• Updates post-acute providers on discharge condition and final plans.
• Reassesses and documents discharge needs throughout stay at minimum every 3 days.

Priority 3: Attends MDRs, Department Meetings, and Additional Trainings

• Attends MDRs on assigned unit.
• Identifies anticipated discharge dates.
• Participates in afternoon huddles and escalates barriers.
• Presents transition plans at MDRs.
• Provides timely follow-up of action items.
• Attends departmental meetings and trainings as scheduled.

Priority 4: Leads Patient-Family Conferences

• Assesses need for patient/family/physician care discussions.
• Schedules and leads patient care conferences to resolve issues.

Priority 5: Escalates Barriers as Appropriate

• Discusses discharge barriers with physician and/or multidisciplinary team.
• Escalates unresolved issues to Supervisor, Manager, or Director.

Insurance and Utilization Management

• Maintains working knowledge of CMS requirements and readmission penalties.
• Maintains working knowledge of insurance/payer benefits.

Documentation

• Documents accurately and timely in the Electronic Medical Record.
• Utilizes standards of professional practice in documentation and communication.
• Ensures documentation complies with organizational, state, and federal guidelines.

Professional Accountabilities

• Participates in continuing education and process improvement activities.
• Adheres to confidentiality, infection control, ethics, safety, and policy standards.
• Demonstrates flexibility, open-mindedness, and adaptability to change.
• Maintains competency in organizational and departmental policies.
• Utilizes professional standards in communication consistent with ethical guidelines.
• Supports and models behaviors consistent with organizational mission, vision, and values.
• Meets all mandatory organizational and departmental requirements.
• Maintains competency in safety and regulatory standards.
• Performs all other duties as assigned or needed to meet department/organization needs.