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Job Summary

The Case Manager, Discharge (MSW) will organize and expedite a treatment plan of care for medically complex and difficult social issues related to hospital progression of care. The incumbent will identify discharge needs and develop a discharge plan, promote communication and collaborative coordination amongst care providers, and provide information and education on community resources. Additionally, the position will coordinate care of patients with clinical partners, provide intervention in cases of child/elder abuse/neglect and guardianship issues, and serve as a resource for treatment decisions surrounding end of life and Medical Power of Attorney.

The Social Worker (MSW) has advanced training and has completed additional fieldwork that promotes a higher level in handling difficult conversations, client needs assessments, public assistance resources, crisis intervention, trauma-informed care, and is eligible for LMSW examination.

Essential Functions and Responsibilities:

• Coordinates care of patients with clinical partners; helps patients advance towards realistic and desirable outcomes.
• Serves as a subject matter expert and functions as a resource person for care team members.
• Serves as a primary mentor for new social work Associates in the Care Coordination department and social work student interns.
• Assesses long term and/or future patient care needs by identifying probable changes in level of independence or functional quality.
• Communicates activity status updates regarding treatment plan with clinical partners.
• Provides information and education on community resources to patient and their families.
• Develops, coordinates, and communicates discharge plans with the patient, family members and care team for medically complex and difficult social issues related to hospital progression. Documents assessment and overall discharge plan in medical record.
• Assists with audits and assessments of discharge planning documentation, as well as aides with complex care coordination situations that may arise.
• Partners with leadership to address concerns related to delays in discharge, barriers to discharge and trends noted.
• Serves as point of contact and resource for immediate post-discharge patient needs.
• Provides intervention in cases of child/elder abuse/neglect and guardianship cases.
• Serves as a resource person related to treatment decisions surrounding end of life and Medical Power of Attorney.
• Facilitates meetings and comprehensive care planning with interdisciplinary team. Delegates work to support team members.
• Utilizes post-acute care facilities for safe and effective discharge planning.
• Collaborates with contracted partners associated with financial needs to facilitate post-acute facility placement.
• Conducts psychosocial assessment as needed for development of appropriate discharge plan for medically complex and difficult social issues.
• Participates in planning and implementing quality improvement activities.
• Performs other duties as assigned.

Qualifications

• Master’s degree in Social Work required.
• A minimum of one year experience in social work required or two-semester internship completed within MWHC Care Coordination department
• Experience with computer technology, specifically experience with Windows based programs, e-mail, and Microsoft Word required.
• Experience in a healthcare field preferred.
• Case Management Certification strongly desired.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.

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Required

Physical Requirements: Constant (67-100% of workday) use of arms and hands; frequent (34-66% of workday) standing, walking, and sitting; occasional (0-33% of workday) bending, stooping, and squatting; ability to lift 35 lbs.; ability to push and pull up to 20 lbs.; auditory and visual skills to include color determination.

Mental Requirements: Possesses critical thinking and analytical skills. Ability to multi-task. Ability to communicate effectively and collaborate with a multi-disciplinary team. Capacity to cope with difficult situations. Ability to tolerate irregular hours including evenings, nights, and weekends.

Environmental Requirements and Exposure Hazards: Potential risk of exposure to radiation and toxic chemicals. Potential for exposure to bloodborne pathogens; must be able to wear appropriate personal protective equipment.

“It is the policy of Mary Washington Healthcare to provide reasonable accommodations to qualified individuals with a disability who are applicants for employment or Associates.”

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