Care Manager Social Worker

adventhealth; Orlando (FL); On-site; USD 70,000 - 95,000; Full time

Job summary

AdventHealth in Orlando, FL seeks a skilled Care Manager to coordinate discharge planning and post-acute care for patients across inpatient, observation, and emergency settings. You will assess psychosocial factors, collaborate with families, and develop comprehensive care plans to ensure timely transitions.

Requires a Master’s degree and 2+ years in care management. Strong communication and data analysis skills, with proficiency in Outlook and EMR systems, are essential.

Qualifications

• Master’s degree required in care management or related field.
• Minimum 2+ years of care management experience.
• Experience with discharge planning and collaboration with multidisciplinary teams.

Responsibilities

• Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate.
• Assesses patients' and families' wholistically for discharge planning needs in inpatient, observation and/or emergency departments.
• Reviews the medical record and incorporates clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with contingency plans throughout the hospital stay for timely care coordination and post-acute care arrangements.
• Communicates with post-acute care services to ensure continuity of care and complete medical records.
• Participates in multi-disciplinary rounds to review patient status, level of care, and discharge plans and escalates delays to leadership as needed.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, barriers to progression, and patient/family needs.
• Provides patient and family advocacy and supports patient rights during hospitalization.
• Communicates with payors for post-acute care authorization as needed.
• Assesses readmitted patients for reasons and coordinates appropriate follow-up actions.

Skills

Interpersonal communication

Critical thinking

Psychosocial assessment

Customer service

Cultural competency

Organization

Outlook & EMR

Adaptability

Care transitions

Community resources

Interview skills

Leadership

Data analysis

Discharge planning

Care regulations

Resource coordination

Education

Master's degree in Social Work, Nursing, or related field

Tools

Outlook

Electronic Medical Records (EMR)

Job description

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.

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

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Schedule:

• Full time
• Shift: Day (United States of America)
• Address: 601 E Rollins St
• City: Orlando
• State: Florida
• Postal Code: 32803
• Status: Full-Time
• Shift: Days

Job Description:

• Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de-escalation services for patients as appropriate.
• Assesses patients' and families' wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate. -Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Provides patient and family advocacy, and support patient's choice and patient rights during hospitalization.
• Communicates with Payors patient's needs for authorization for post-acute care as needed.
• Assesses readmitted patients for the patient's and family's perceived reasons for the readmission.
• Other duties as assigned.

Knowledge, Skills, and Abilities:

• Excellent interpersonal communication and negotiation skills [Required]
• Critical thinking and problem-solving skills [Required]
• Psychosocial assessment skills [Required]
• Customer service skills [Required]
• Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change [Required]
• Effective organizational skills [Required]
• Computer proficiency with Outlook e-mail and electronic medical records [Required]
• Flexible in a complex and changing healthcare environment [Required]
• Understanding of pre-acute and post-acute venues of care and post-acute community resources [Required]
• Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources [Required]
• Strong interview, assessment, and organizational skills [Required]
• Leadership skills [Required]
• Data analysis skills [Required]
• Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement [Preferred]
• Knowledge of state and federal guidelines pertinent to Care Management [Preferred]
• Ability to identify appropriate community resources and to work collaboratively with patients, families, multidisciplinary team and community agencies to achieve desired patient outcomes [Preferred]
• Knowledge of state and federal guidelines pertinent to care management [Preferred]

Education:

• Master's [Required]

Work Experience:

• 2+ care management