Northern Light Mercy Hospital
Department: Care Management
Position is located: Mercy State Street
Work Type: Full Time
Hours: 40 hours
Work Schedule: 8:00 AM to 4:30 PM
The Care Manager/Social Worker, as part of a multidisciplinary team, including the patient/family, physicians, nurses therapists and payors ensures the patient’s progress in the acute episode of care through post discharge and is quality driven while being efficient and cost effective. The incumbent interacts with patients, family members, healthcare professionals, and community and state agencies in this effort. The Care Manager/Social Worker serves as a liaison between the hospital and community agencies or facilities for the exchange of clinical and referral information. The Care Manager/Social Worker reviews high risk patients from a psychosocial and medical perspective and assesses the psychological needs of patients and families and provide information, support, counseling, care management, and referrals to appropriate resources. The Care Manager/Social Worker and RN Care Manager work collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum. The expertise of the Care Manager/Social Worker is sought to resolve psychosocial patient care issues and to develop complex patient transition/discharge plan as needed. The Care Manager/Social Worker is responsible for maintaining hospital compliance with the Quality Improvement Organization (QIO) series provides case review to third party payers and assisting in the denial and appeals process as well as assessing quality, levels of care and identifying and reporting potential risk management issues. The incumbent performs duties and tasks in accordance with performance standards established for the job. The incumbent may have access to highly confidential patient, employee and/or Mercy proprietary information, and must handle & protect the information in accordance with hospital & system policies, HIPAA requirements and the highest level of ethical standards. The incumbent is responsible for reporting all security events, potential events, or other security risks to the organization. The incumbent is responsible for participation in and completion of all patient safety initiatives appropriate to the position, and conducts all job responsibilities according to the Mission and Values of Mercy Hospital.
1. Works in conjunction with physicians, nurses, Care Management Team and others to assess, plan and initiate patient plan of care.
- Provides assessment, social services, and counseling to patients and their families in relation to social, psychological, financial, and family situations which will allow timely discharge facilitation.
- Obtains, interprets, and communicates necessary information regarding patients and families, including social history information, to staff and physicians.
- Performs clinical assessments and initiates interventions on assigned patients as appropriate to ensure optimal patient outcomes. Should be done through collaboration with multidisciplinary team.
- Attends Integrated Rounds per unit schedule.
- Meets with patients and families to provide psychosocial support as needed.
2. Facilitates and coordinates details of placement and actual discharge to appropriate agencies.
- Discusses recovery plans, psychosocial needs and medical information with facilities.
- Provides and updates referrals to facilities through online/software discharge planning tools.
- Acts as a liaison between hospital and community agencies.
- Arranges time and mode of transportation to facilities for patients.
3. Facilitates and coordinates individualized discharge plan.
- Arranges and participates in care conferences.
- Provides adequate avenues of communication through on-going documentation in MediTech, eDischarge and telephone/verbal reporting or electronic tools.
- Coordinates and communicates with home care agencies regarding expected standards of care for requested specific treatments and psychosocial needs.
- Assists patients and families with obtaining community assistance by referral to proper resources.
4. Serves as a resource to physician and hospital personnel regarding available agency, facility, and community services to assist in discharge planning.
- Develops and maintains good working relationships with outside community health and social agencies. Reaches out to the community to develop new resources for meeting patient needs.
- Discusses specific continuing care needs with physicians and hospital personnel on a regular basis.
- Arranges and participates in care conference.
- Discusses on-going continuing care needs of patients with multidisciplinary team daily.
5. Completes appropriate State of Maine forms.
- Monitors the completion of the MED by Goold for all first time Medicaid transfers to nursing facilities.
- Alerts Goold to complete The MED on Medicaid patients with expired bed holds.
- Alerts Goold to complete The MED on Medicaid patients with need for community programs.
6. Ensures adherence to Quality Standards.
- Participates in departmental and hospital Quality Improvement programs.
- Provides adequate documentation of initial assessments, on-going writing of progress notes and reviewing of all referrals for accuracy and content prior to discharge.
- Accepts responsibility for further development of professional learning and growth.
7. Medical Record Review:
- Conducts inpatient admission reviews for appropriateness of setting.
- Conducts on-going case review for continued stay criteria and enters data.
- Monitors quality of care using predetermined criteria.
- Reports potential risk management issues as through medical record review.
- Enters data as requested to support Quality Improvement initiatives in Midas.
- Documents in appropriate electronic system by the close of business each day.
- Consults with Physician Advisor and leadership as necessary to resolve barriers through appropriate administrative and medical channels.
9. Computer Skills:
- Demonstrates competency in accessing and documentation in Midas, Meditech, Milliman, eDishcarge and email system
10. Identifies patients and families in need of social work services
- Performs high-risk screenings
- Responds to patient and family request for case work services.
11. Provides psychosocial assessments of the patients and families in relation to the crises of acute and chronic illness.
- Consult with patient to determine psychosocial concerns and needs.
- Meets with family for their input around concerns and needs in relationship to the illness.
- Reviews medical charts/nurse assessment forms for further insight into patient’s needs.
12. Develops and implements appropriate treatment plans and interventions.
- Utilizes crisis interventions to mobilize resources in response to crises.
- Counsels and supports individual, families to help adjust and cope with illness.
- Make referrals to appropriate community resources.
- Refers patient and families to appropriate resources regarding insurance issues.
- Works as in advocate within and without the hospital.
13. Professional Development:
- Assumes responsibility for own professional growth and on-going education
- Seeks opportunities to meet learning needs through workshops and literature.
- Maintains knowledge of necessary QIO transmittal services to facilitate appropriate level of care and denial activities within the hospital.
14. Serves on committees as appropriate
Competencies and skills:
* 2+ years of relative work experience required.
* Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
* Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
* Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level.
* Exercises Sound Judgment & Decision Making: Understands and processes complex information, which allows for appropriate and accountable conclusions. Does not react too quickly or slowly. Balances facts, goals, and potential approaches taking the appropriate criteria into account. Makes active decisions and commits oneself by communicating confidently and respectfully.
* Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
* Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
* Utilizes Resources Effectively: Understands how to get the most out of available resources and uses cost-benefit thinking in decision-making and in setting priorities. Monitors and analyzes resource usage to identify and eliminate areas of waste and maximize resources. As a leader, defines targets and provides appropriate means; oversees progress and makes adjustments when necessary. Appropriately delegates work, sets clear direction and manages workflow and time.
* Licensed Clinical Social Wkr (LCSW)
* Potential exposure to abusive and/or aggressive people.
* Potential exposure to diseases or infections.
* Potential exposure to hazardous materials.
* Potential exposure to noise levels being uncomfortable.
* Potential exposure to noxious odors.
* Potential exposure to very hot or cold temperatures.
* Work with computers, typing, reading or writing.
* Lifting, moving and loading 20 to 30 pounds.
* Continuous sitting.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status