MSW, Patient Resource Manager (8a-430p) Case Management - Johnson City, TN

Accountable for assessment & ongoing re-assessment of the patient’s physical, emotional, social, and financial needs and the proactive development of a comprehensive plan of care that achieves a timely and sustained discharge. Demonstrates understanding and sensitivity of the diverse cultural backgrounds of patients and their families. Possesses working knowledge of disease processes, appropriate clinical interventions and the immediate and long term care needs of high-risk populations of all age groups consulting medical and nursing colleagues as needed.

Facilitates complex patient care issues such as the need for a legal guardian, lack of U. S. citizenship, abuse/neglect (children & adults), domestic violence, sexual assault, adoption, uninsured/underinsured, need for behavioral health treatment, end of life care and homelessness. Provides crisis intervention services as needed.

Possesses excellent interpersonal communication, judgment and problem solving skills. Able to take initiative, demonstrate follow-through and work independently. Collaborates with medical staff and the multi-disciplinary healthcare team to complete a psychosocial assessment of patient and family needs and goals, and to develop, advocate, and expedite patient-centric post-acute care plans.

Assesses the capacity of home caretakers to cope effectively with patient needs. Identifies obstacles to compliance with healthcare team recommendations. Recognizes need for and facilitates patient/family care conferences.

Demonstrates the ability to simultaneously formulate primary and back-up discharge plans so delays are avoided. Comes prepared to daily huddles; facilitates timely decision making and assigns accountability for follow-up to team members in order to advance the discharge plan. Intervenes to remove barriers that impede the efficient progression of care.

Provides list of providers to honor patient preferences and choice. Provides patient/caregiver with healthcare and social services information and educates about how to access for support after discharge. Ensures continuity of care through timely and accurate hand-off communication including full completion of required forms.

Documents assessment, plans, interventions, and avoidable delays in Epic and updates documentation when changes in the patient’s health, emotional, or social condition occur. Keeps current with all regulatory changes that affect delivery or reimbursement of acute care services including HIPPA, Patient Bill of Rights, EMTALA, Medicare Outpatient Observation Notice (MOON) and Hospital Initiated Notice of Non-Coverage (HINN).

Actively participates in quality improvement activities through collection of data, analysis, and development & monitoring of action plans to improve key department indicators of performance. Coordinates with the Utilization Management team to manage concurrent denials. Escalates issues such as barriers or delays to Manager/Director to ensure timely resolution.

Follows procedure for delivery of second Important Message from Medicare (IMM) to patient or representative within 2 days of discharge from hospital. Maintains professional knowledge, attends staff meetings, educational offerings, and accepts accountability for the information presented. Gives report to (and receives report from) weekend and on call staff, and the colleague who is covering when taking PTO As a member of the Patient Resource Management team, the Social Worker will collaborate with Case Managers to ensure timely movement of patients through the continuum of care.

Discharge dispositions may include: inpatient rehabilitation, transitional SNF, nursing home placement, inpatient psychiatric facilities, home with home health, home with medical equipment, or home. Social workers are primarily responsible for: - Administering psychosocial assessments - Identifying and coordinating continuum of care needs, including discharge assessment and planning - Cultivating therapeutic relationships with patients and families - Incorporating patient and family preferences and strengths into a collaborative plan of care - Advising, educating, advocating for and facilitating access to neededresources - Responding to needs of special populations such as the homeless, substance abusers, and families with complex social situations - Ensuring appropriate length of stay by addressing patient, family, and system barriers to discharge Additionally, social workers are included in a variety of hospital, departmental, and community committees that may involve planning and development of programs and services.

Social workers are actively involved in disaster response that provides crisis intervention in the family crisis waiting area. As such, social workers are required to be available on an on-call basis 100% of the time. Social workers plan for and participate in performance improvement activities.

The social worker will demonstrate competency in the case management care of the neonate, infant, child, adolescent, adult, and geriatric patient. The social worker may be assigned to specific clinical areas such as cardiology, neurology, orthopedics, and oncology.

Master's degree in Social Work, Sociology, or Psychology from an accredited university. Two years experience in case work or counseling in a health care or social service setting. Experience in an inpatient care setting preferred.

Licenses and

Valid and active social work license preferred CPR required BLS Required Work

Day On Call: No Weekends: No

No Travel Shift Details: 8a-430p City/State: Johnson City, TN Location: Johnson City Medical Center