Social Work Consultant II

Job Summary

Discharge Planning: The primary role of the Medical Social Worker II for hospital settings is to facilitate the execution of approved and appropriate inpatient discharge plans between facilities or into the community. Under general direction of the Continumm of Care Leader and via clear and consistent communication with the onsite care management staff, delivers age-appropriate clinical social work insight and care to members and their caregivers in accordance with agency policy and procedure and state and federal regulations. The Medical Social Worker II serves as an integral member of the healthcare team ensuring coordination of discharge/transition planning and providing referrals to internal resources within the Kaiser Permanente network, information to community resources and other social work services to meet the complex needs of patients and families transitioning from hospital settings.

Essential Responsibilities

• DISCHARGE PLANNING:
• Responsible for overseeing or participating in individual discharge plans which assist members and families to transition to the appropriate level of care upon the completion of the acute Treatment Plan with the measure of restoring social, emotional, financial, and environmental factors which affect and/or affected by the acute inpatient stay.
• Partners with multidisciplinary teams to identify needs and collaborate and execute individual discharge plans.
• Discuss options for care proactively including Kaiser resources and external community/government resources to assist member and caregiver(s) in developing short- and long-term care plans as appropriate.
• Collaborates with other disciplines in assessing, planning, and providing services for patients utilizing biopsychosocial information.
• Coaches member pre-discharge in advocating for self to receive appropriate services within Kaiser and in the community.
• Ensures member and caregiver(s) are updated with approved discharge plans.
• Takes, reviews, evaluates, and prioritizes written and oral referrals.
• Maintains documentation, records, and data collections.
• Responsible for completion of required documents in a complete and timely manner.
• Functions as liaison to the Post-Acute Team to assure appropriate, timely placement of Kaiser members in facilities.
• Serves as a liaison between patient and Kaiser maintaining positive relationship with Kaiser and providing for continuity of care.
• Identifies appropriate levels of care and facilities for referred patients, were applicable.
• Obtains placements, where applicable.
• Collaborates with internal and external resources in Kaiser and the community to meet mutually agreed upon goals and objectives.
• Provides information and referral to community resources as requested.
• Coordinates exchange of information among Kaiser, families, members, and all facilities involved in the discharge plan.
• Determines application of Kaiser, Medicare, and any additional insurer benefits to specific patient situations.
• Coordinates the application of all active insurance coverage for the purposes of care transitions and ensures that coverage benefit coordination is communicated to all facilities involved.
• Participates in Utilization Management/Quality Assurance activities.
• Assists in coordinating communication between regional offices, clinics, hospitals, and field staff.
• Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management.
• Works cross-functionally with other departments in striving to meet organizational goals and objectives.
• Works with referral sources to clarify and complete required clinical and psychosocial information.
• Provides consulting services to the local Kaiser Permanente Acute Care Centers, Clinical Decision Units, and core hospital KP partners on occasion.
• Escalates issues and barriers timely and appropriately.
• Perform other related duties as necessary.