Continuing Care Manager - Social Worker

Dartmouth-Hitchcock Health; Lebanon (NH); Vor Ort; USD 70.000 - 90.000; Vollzeit

Zusammenfassung

Dartmouth-Hitchcock Health seeks an inpatient Palliative Care Social Worker to assess and support patients and families navigating serious illness and end-of-life care at the Jack Byrne Center and Dartmouth-Hitchcock Medical Center. You will coordinate interdisciplinary care, develop psychosocial treatment plans, and advocate for access to services while monitoring outcomes across settings.

Candidates should hold an MSW with at least five years of clinical experience, possess strong

Qualifikationen

• Master’s Degree in Social Work (MSW) required.
• Minimum of 5 years of clinical Social Work experience preferred.
• Strong communication and leadership abilities; ability to negotiate and resolve conflicts.

Aufgaben

• Coordinate interdisciplinary care across the care continuum for patients and families.
• Conduct comprehensive psychosocial assessments and develop treatment plans.
• Advocate for patient needs and navigate complex care systems to remove barriers.

Kenntnisse

Critical thinking

Leadership

Communication

Self-starter

Conflict resolution

Computer skills

Ausbildung

MSW

Tools

EMR systems

Microsoft Office

Jobbeschreibung

Overview

The inpatient Palliative Care social worker facilitates psychosocial assessments and clinical interventions with patients and families navigating serious illness and end-of-life at the Jack Byrne Center and Dartmouth-Hitchcock Medical Center.

Responsibilities

• Manages and coordinates interdisciplinary care of defined populations through the care continuum from wellness through end of life from a psychological, social and environmental perspective.
• Identifies high risk patients requiring on-going coordination of care; performs a comprehensive patient/family assessment, develops a comprehensive treatment plan that will span the continuum of psychosocial issues, implements a plan of care to provide continuing support and coordination for patient/family with multiple complex system needs, manages benefits and negotiates continuing care services for enrollees in various health insurance plans, etc.
• Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in regards to psychological, social and environmental areas.
• Monitors the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.).
• Shares assessment and psychological, social and environmental care plan data with patient/family consent as the patient moves through different care settings.
• Identifies gaps in the care continuum and work with the community and provider networks to expand access to needed psychological, social and environmental services.
• Participates in the development of disease management strategies and identifies the appropriate measures for the evaluation of outcomes.
• Participates in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization.
• Collects and evaluates data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization.
• Performs other duties as required or assigned.

Qualifications

• Master’s Degree in Social Work (MSW) with 5 years of clinical experience required.
• Critical thinking skills, strong leadership and communication abilities, the ability to be a self-starter, negotiate, and handle conflict resolution desired.
• Understanding of and comfort using computers desired.
• Collaborative team player, use of systems approach in planning, problem solving and decision making, creativity, innovation, risk taking, autonomy, flexibility, receptiveness to change and a commitment to professional growth desired.

Required Licensure/Certifications

• None