Social Work Care Manager
: Job Details :

**All the benefits and perks you need for you and your family:**

Paid Days Off from Day One

Student Loan Repayment Program

Career Development

Whole Person Wellbeing Resources

Mental Health Resources and Support

**Our promise to you:**

Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that **together** we are even better.

**Schedule:** Full Time

**Shift** :Days

**The community you'll be caring for:** AdventHealth North Pinellas

**The role you'll contribute:**

The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Social Worker is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Work Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Social Work Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

**The value you'll bring to the team:**

Provides consult services for foster care and adoptions.

Assists the health care team in the patient assessments and placements for mental health services.

Facilitates full team discussion including patient and family when ethical dilemmas arise.

Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed

Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.

Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes.

Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.

Incorporate clinical, social and financial factors into the transition of care plan.

Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.

Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient

Qualifications

**The expertise and experiences you'll need to succeed:**

Masters in Social Work and 3 years experience

Care Management discharge planning experience

Knowledge of state and federal guidelines pertinent to care management

BLS Certification

Licensed Clinical Social Worker (LCSW)

ACM/CCM certification

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

**Category:** Case Management

**Organization:** AdventHealth North Pinellas

**Schedule:** Full-time

**Shift:** 1 - Day

**Req ID:** 24019814

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.