Social Work Care Manager Ottawa FT Days
Company: AdventHealth Ottawa
Posted on: January 6, 2022
DescriptionSocial Work Care Manager -AdventHealth Ottawa
Location Address: -1301 S. Main Street, Ottawa, KS 66067 Top
Reasons To Work At AdventHealth Ottawa
- Family friendly community
- Excellent cost of living
- Five major recreational lakes
- Many annual events and festivals
- Environment committed to patient care Work Hours/Shift:
- FT, Days You Will Be Responsible For: - - -
- Psychosocial Assessment and Interventions
- Assesses patient's and family's psychosocial risk factors
through evaluation of prior functioning levels, appropriateness and
adequacy of support systems, assisting those coping with adjusting
to significant life transitions
- Intervenes with patients and families regarding emotional,
social, and financial consequences of illness and/or disability;
accesses and mobilizes family/community resources to meet
- Serves as a resource to provide information and intervention
related to treatment decisions, terminal illnesses and end-of-life
- Provides grief counseling and crisis intervention skills
- Advocates for patient and family empowerment and independence
to make autonomous health care decisions and access needed services
within the healthcare system
- Provides de-escalation services for patient/family as
- Provide Motivational Interview techniques for patients with
substance use and addictive disorders
- Provides patient/family education, adjustment-to-illness
counseling, grief counseling and crisis intervention
- Provides education to patients/families/caregivers regarding
resource options and coping with diagnosis, treatment and
- Works in collaboration with hospital and community agencies to
obtain needed services and resources for
- Receives referrals for psychosocial complex needs from the
health care team.
- Provides assessment and reporting interventions in child
abuse/neglect, domestic violence, adult/elderly abuse, child
protection, sexual assault, and human trafficking as
- Provides consult services for patients who may possibly lack
decision making capacity. - Follows the guardianship (temporary/
permanent) policies and procedures and coordinates with Care
Management leadership throughout the process.
- 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
- 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
- Identifies and collaborates with the interdisciplinary team and
hospital operations to resolve potential barriers to transition of
care plan achievement.
- Collaborates with the multidisciplinary healthcare team daily
in multidisciplinary rounds to efficiently communicate and
facilitate high quality patient progression of care and transitions
- Evaluates the potential for readmissions throughout the patient
stay through the monitoring of each patient's readmission risk
scores and coordinating readmission mitigation interventions.
- Assures Social Work consults are completed for specialty
services related to psychosocial needs, decision making needs for
patients who lack capacity, patient/family adjustment needs and
psychosocially complex cases.
- Develops discharge plan with appropriate contingency plans
throughout the hospital stay to enable adaptation to evolving
patient care needs and ensure timely care coordination.
- Escalates issues barriers to appropriate level of Care
- Assists with End of Life conversation, Living Wills, Advance
Directives, Power of Attorney, Community DNR.
- Facilitates patient care conferences with multidisciplinary
team as needed.
- Establishes and documents, based on the predicted DRG and
multidisciplinary team member's input, Anticipated Date of
Transition (ADOT) and destination and updates, as needed.
- Actively participates in daily Multidisciplinary Rounds to
review progression of care and discharge plan for all assigned
- Proactively identifies patients who no longer meet medical
necessity and escalates potential denials, documents avoidable
days, and facilitates progression of care.
- Collaborates with Utilization Management staff for
collaboration on patient status changes and medical necessity
- Ensures all patients on assigned unit(s) are moved timely and
effectively to appropriate levels of care
- Ensures reassessment of discharge needs provided anytime a
patient's condition changes and/or the circumstances impacting the
provision of post-hospital care changes.
- Ensures patient notifications are provided and documented in a
timely manner for compliance: - Important Medicare Letters (IML),
Medicare Outpatient Observation Notice (MOON), Patient Choice, and
Beneficiary Notice Letter (BNL).
- Communicate with patient/family the possible need to pay for
services out of pocket.
- Ensures primary care physician identification and scheduling of
follow-up PCP and specialist appointments for post-hospital follow
- Ensures discharge disposition accuracy and consistency in the
EMR on all discharge patients.
- Serves as a content expert regarding payor information and
educates interdisciplinary team and patients/caregivers regarding
- Maintains clinical competency and current knowledge of
community resources, post-acute care providers and payor
requirements to perform job responsibilities.
- Participates in department and hospital Performance Improvement
- Provides necessary patient care coverage and assistance with
other duties as assigned when needed.
- Promotes individual professional growth and development by
meeting requirements for mandatory/continuing education, skills
competency, supports department-based goals which contribute to the
success of the organization.
- Participates in facility and department regulatory and
- Social Work Care Manager serves as a preceptor
- Social Work Care Manager participates in department education
(bulletin or presentation) with topic and content approved by
Facility CM Director QualificationsWhat You Will Need:
- Masters (MSW) and 3+ years of experience required
- Care Management Discharge planning experience preferred
- ACM/CCM preferred Job Summary: 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. - This facility is an equal opportunity employer
and complies with federal, state and local anti-discrimination
laws, regulations and ordinances.
Keywords: AdventHealth Ottawa, Lawrence , Social Work Care Manager Ottawa FT Days, Executive , Ottawa, Kansas
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