Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Social Work Case Manager is responsible and accountable for ensuring high value patient care that is coordinated, efficient and aligned with institutional clinical and financial objectives. In collaboration with the healthcare team, the Case Manager utilizes evidence based practice to ensure that specific patient outcomes are reliably achieved and that resources are appropriately used within designated fiscal time frames. With our members of the health care team, the Case Manager participates in the ongoing evaluation of practice patterns and supports efforts to improve patient care and enhance efficiency of operations. The Case Manager interacts with others in the identification of trends and barriers to all aspects of care. Through this interaction, the Case Manager identifies and works toward a resolution as a part of the multidisciplinary team.
EEO/AA/Disability/Veteran

1. As part of the interdisciplinary health care team, coordinates and ensures the implementation of the plan of care, utilizing the principles of case management.

1.1 Establishes a system for coordinating the care of a patient throughout the continuum of care, linking the inpatient care with outpatient care, services and case management.

2. Optimizes the efficiency of hospital systems which impact quality and/or length of stay

2.1 Identifies and monitors compliance with documenting variances from established parameters in the clinical pathway or treatment plan.

3. Utilizes information obtained from various resources available to:

3.1 Ensure that each patient meets the clinical needs for admission, treatment, and discharge and initiates appropriate follow through with the health care team.

4. Assist clinicians in documenting the appropriateness of admissions and continued stays

4.1 Responsible for Medicare notices of non-coverage and help provide appropriate documentation to appeal inappropriate denials.

5. Ensures that an appropriate discharge plan is developed and implemented with the health care teams members to include:

5.1 Identifying service, treatment and funding options;

6. Ensures that the discharge plan provides a continuum of care with the appropriate outpatient physician and needed services.

7. Ensure that the appropriate outside agencies are contacted and necessary referrals are initiated and followed through.

8. Works collaboratively with PSM and unit leadership team to actively involve clinical nurses in the assessment and planning for patient's discharge to facility.

8.1 Links patient and family with the appropriate institutional or community resources, advocating on their behalf for scarce resources, and developing new resources where gaps exist in the service continuum.

9. Along with other members of the health care team, acts as a patient advocate.

9.1 Exhibits awareness of ethical/legal issues concerning patient care and strives to manage situations to reduce risk.

EDUCATION

BSW required and MSW preferred

EXPERIENCE

Minimum of 2 years of relevant experience

SPECIAL SKILLS

Lead Transitional Care rounds with physicians, nurses and other members of the health care field. Case Management experience a plus.

PHYSICAL DEMAND

None

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