Social Worker Care Manager - Case Management - St. Francis

The Social Worker Care Manager is responsible for providing appropriate interventions and discharge planning services to patients and families and facilitates a smooth transition for the patient throughout the continuum of care by accessing hospital, community, and governmental resources. They also provide clinical supervision to peers, Social Workers, and students.   

Essential Functions:  

• Identifies and prioritizes patients in need of social  services, using a holistic approach inclusive of biopsychosocial, functional, cultural, spiritual, and financial factors.  Plans with the patient, caregivers and members of the healthcare team to maximize health care responses, quality and cost-effective outcomes.   Monitors and revises the plan as indicated when patient condition changes.  

• Completes all necessary documentation.  Maintains, clear, concise, and timely documentation in the patient record to reflect the needs of the patients.    

• Documentation will reflect plan of care to address post hospital care needs and resources and evidence of patient, family, or caregiver involvement in planning.  Ensuring patient’s and caregiver’s treatment goals and preferences are incorporated into the transition of care planning and communicated to the multidisciplinary team.  

• Follow standardized practices and process related to Advance Care Planning, Length of Stay management and readmission prevention.  

• Supports denial prevention related to medical necessity through addressing / removing barriers to progression of care and participating in Interdisciplinary Discharge Rounds.  

• Supports and promotes assertive, proactive care for patients, assisting in removing barriers related to achieving timely testing and treatment.  Ensures resources are utilized appropriately and offering alternatives to acute care to the care team.  

Education: 

• Bachelor of Social Work (required)  

• Master’s degree in social work or healthcare related field (preferred) 

 
Licensure/Certification: 

• BLS Basic Life Support – American Heart Association (required)  

• Licensed as a Social Worker in state of practice (required, preferred in VA)  

• Accredited Case Manager Certification (ACM) from American Case Management Association or Certified Case Manager (CCM) from Commission for Case Manager Certification (preferred)  

Experience: 

• 1 year of experience in clinical setting (required)  

• 3 year of experience in an acute care clinical setting (preferred)  

• Ambulatory or post-acute, care coordination experience (preferred)  

Training: 

None 

Skills and Abilities: 

Hard/Tech/Clinical Skills:  

Social Work  

Care Management  

Ethics  

End of Life Ethics  

Patient Advocacy  

Clinical Supervision  

Microsoft office  

Ability to prioritize many simultaneous demands and tolerate frequent interruptions.   

Soft/Interpersonal Skills:  

Attention to detail  

Critical thinking  

Communication with family members  

Conflict resolution  

Active listening  

Relationship building  

Effective problem solving  

Teamwork  

Open to change  

Collaboration  

Communication  

Displays empathy  

Negotiation skills  

Time management  

Prioritization