Registered Nurse (RN) - Master Social Worker (MSW) Case Manager - Bon Secours St. Francis Hospital

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Scheduled Weekly Hours

40

Work Shift

Days (United States of America)

HOURS: Monday - Friday, 8:00am - 4:30pm

Master Social Worker (MSW) Care Manager

Primary Function/General Purpose of Position

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 Job 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.

Works in collaboration with revenue cycle partners to help remove barriers to ensure patients are in the appropriate classification as guided by the physician.

Works in conjunction with patient access to ensure all regulatory letters are delivered to the patient in a timely manner.

Participates in department clinical outcome projects as well as process improvement initiatives within the care management department.

Works collaboratively with peers to achieve facility and department goals and daily work as evidenced by appropriate and timely communication which is respectful and clear.

Shares responsibilities, promoting team-based approach to accomplish work.

Strong collaborative partnerships with other members of the care team.

Supports and follows compliance rules and regulation as mandated by CMS and Conditions of Participation for discharge planning and utilization management. Addresses opportunities or potential concerns with leadership.

Stays abreast of community resources available to facilitate sate patient transitions of care and remains current on clinical advancements related to primary patient population.

Provides supervision for other social workers and students as appropriate.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.

• Licensing/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)

Education

• Bachelor of Social Work (required)
• Master’s degree in social work or healthcare related field (preferred)

• Work 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

Language

None

Patient Population

Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit.

Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures.

• Neonates (0-4 weeks)
• Infant (1-12 months)
• Pediatrics (1-12 years)
• Adolescents (13-17 years)
• Adults (18-64 years)
• Geriatrics (65 years and older)

Working Conditions

• Periods of high stress and fluctuating workloads may occur.
• General office environment.
• May be exposed to high noise levels and bright lights.
• May be exposed to physical altercations and verbal abuse.
• May be exposed to limited hazardous substances or body fluids.*
• May be required to use physical restraints.
• May be exposed to human blood and other potentially infectious materials.*
• May be exposed to adverse weather conditions; cold, hot, dust, wind, etc.
• May have periods of constant interruptions.
• Required to car travel to off-site locations, occasionally in adverse weather conditions.
• Prolonged periods of working alone.

• Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

• Physical Requirements
• Physical Demands
• Frequency 0% 1-33% 34-66% 67-100%
• Lifting/ Carrying (0-50 lbs.) X
• Lifting/ Carrying (50-100 lbs.) X
• Push/ Pull (0-50 lbs.) X
• Push/ Pull (50-100 lbs.) X
• Stoop, Kneel X
• Crawling X
• Climbing X
• Balance X
• Bending X
• Work Position
• Frequency 0% 1-33% 34-66% 67-100%
• Sitting X
• Walking X
• Standing X
• Additional Physical Requirements/Hazards
• Physical Requirements
• Manual dexterity (eye/hand coordination)
• Perform shift work
• Maneuver weight of patients
• Hear alarms/telephone/audio recordings
• Finger Dexterity
• Acuity – near
• Hazards
• Use of Latex products

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.
• 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

Registered Nurse (RN) Care Manager

Primary Function/General Purpose of Position

The RN Care Manager is responsible for providing coordination of care for patients to support safe, seamless, timely transitions across the continuum.

This role utilizes a collaborative process, the RN Care Manager identifies (using quantitative and qualitative methods), assesses, plans, implements and evaluates the options and services required to meet an individual’s health and health related needs, including social- determinants that affect ones’ overall wellbeing.

The RN Care Manager is responsible for screening, identification, and assessment of individuals in need of active Case Management services and promotes the right resources, at the right time and at the right place.

Essential Job Functions

Identifies and prioritizes patients in need of care management 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. Handovers are expected to be utilized at points of level of care change, staff change, as well as care transitions.

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.

• Shares responsibilities, promoting team based approach to accomplish work.
• Strong collaborative partnerships with other members of the care team.
• Supports and follows compliance rules and regulation as mandated by CMS and Conditions of