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An established industry player is seeking a dedicated Clinical Social Worker to join their compassionate team. This role is pivotal in facilitating patient care through effective resource coordination and psycho-social assessments, ensuring optimal health outcomes and preventing avoidable readmissions. You will work closely with patients, families, and healthcare professionals to develop and implement transition plans that align with patient needs and available resources. With a commitment to diversity and inclusion, this organization offers an enriching environment where your contributions will have a meaningful impact on the community's health and well-being. If you are passionate about making a difference in healthcare, this opportunity is for you.
Job Description - Clinical Social Worker Case Management Contingent Days (2506000236)
Description
DMC Huron Valley-Sinai Hospital in Oakland County is committed to outstanding customer service and medical care. This hospital features the Harris Birthing Center with all private birthing suites, the Charach Cancer Treatment Center (affiliated with the Barbara Ann Karmanos Cancer Center), cardiac services, and comprehensive inpatient and outpatient diagnostic care. For emergency services, obstetrics and ambulatory surgery, Huron Valley-Sinai consistently ranks among the top hospitals in the nation.
Summary Description
The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient's resources and right to self-determination. The individual in this position has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:
This individual's responsibility will include the following activities: a) complex psycho-social transition planning assessment and reassessment and intervention, b) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, c) care coordination, d) implementation or oversight of implementation of the transition plan, e) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, f) making appropriate referrals to other departments, g) communicating with patients and families about the plan of care, h) collaborating with physicians, office staff and ancillary departments, i) assuring patient education is completed to support post-acute needs , j) timely complete and concise documentation in Case Management system, k) maintenance of accurate patient demographic and insurance information, l) and other duties as assigned.
POSITION SPECIFIC RESPONSIBILITIES:
Transition Management
· Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients
· Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
· Completes Complex/Psycho-social assessment and plan for patients identified as high risk for readmission.
· Provides psycho-social assessment and intervention for patients identified with identified needs including behavioral health, lack of support systems, financial barriers, end of life, and/or medication adherence.
· May delegate the implementation of the transition plan to LVN/LPN or Assistant staff and follows up to ensure the transition plan is completed timely and accurately.
· Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers.
· Provides information to patients to make informed choices when community services per Tenet policy.
· Completes Final Discharge Disposition Form Assessment for Medicare patients per Tenet policy.
· Completes timely, complete and accurate documentation in the Tenet Case Management system to communicate information to the care team and provide documents needed in the patient record (40% daily, essential).
Care Coordination
· Screens patients for factors that may affect the progression of care and intervenes as needed to promote timely and appropriate throughput.
· Conducts assessments and stratifies patients at risk for readmission or in need of Case Management services.
· Assists with adoption/abuse/neglect cases and reporting of appropriate cases to local, state and/or federal agencies.
· Ensures the plan of care is consistent with patient choice and available resources.
· Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care.
· Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimal outcomes (40% daily, essential).
Education
· Ensures and provides education to patients, physicians and the healthcare team relevant to the safe and timely patient transition.
· Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options.
· Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge (10% daily, essential).
Compliance
· Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services.
· Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies.
· Operates within the Social Work scope of practice as defined by state licensing regulations (10% daily, essential).
Qualifications
Minimum Qualifications
Skills Required
Job Type : PT2Y
Shift Type : Days
JOIN OUR TEAM
QUALITY CARE DELIVERED BY COMPASSIONATE PEOPLE
We know it takes a special person to work in healthcare, and we are committed to providing our people with an enriching and rewarding environment. We deliver the resources, tools and support our employees need to serve our patients and customers in the best way possible — so we can create happier, healthier communities.
COMMITTED TO DIVERSITY AND INCLUSION
At Tenet, we believe in a diverse and inclusive environment, one that is grounded in our dedication to the health and well-being of all people. Respecting, nurturing and encouraging diversity of thought, background and experience contribute to positive work environments that result in exceptional patient care. We embrace diversity because it's our culture, and because it's the right thing to do.
Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status.
Upon receipt of a conditional offer of employment, applicant will be required to undergo a criminal background check.
Tenet participates in the E-Verify and Work Opportunity Tax Credit (WOTC) programs.