Discharge & Care Coordination Social Worker

McLaren Health Care; Petoskey (MI); On-site; USD 65,000 - 90,000; Full time

Job summary

McLaren Health Care seeks a social work case manager to assess and intervene to help patients and families overcome social, economic and health-related barriers, coordinating discharge planning and linking them to appropriate resources.

You will triage within 24 hours, collaborate with the care team, coordinate community services (Meals on Wheels, home care, etc.), arrange family conferences, monitor readmission risk, and document plans in the EMR for safe transitions.

Responsibilities

• Performs high level triage of all patients, focusing on complex psychosocial or financial issues, placement needs, and community service needs within 24 hours of admission.
• Receives RN Care Manager referrals to social work based on identified Social Work Triggers (see SOP).
• Identifies and assesses barriers early in the patient’s stay, formulating a plan with patient, family, and care team, payers, and resources.
• Assesses needs for support and community services (Meals on Wheels, Sitters, etc.); educates and refers to resources, arranges appointments, and coordinates with agencies.
• Assesses readmission risk and initiates interventions to aid in transitioning along the care continuum.
• Participates in family care conferences and interdisciplinary meetings, providing consultation to patient, families, and staff.
• Identifies and reports avoidable delays from the plan of care to leadership.
• Identifies patient/family preferences and strengths to guide the interdisciplinary team.
• Interviews patient and significant others to assess psychosocial situation and identify a primary contact.
• Develops discharge plan with patient, family, physician, and health care team.
• Manages complex cases and advocates for patients and families as discharge plans are developed.
• Uses insurance knowledge to maximize appropriate resource use.
• Documents assessment, plans, interventions, barriers, and reassessments in the EMR to facilitate discharge and transitions.
• Collaborates with RN Care Manager and others to ensure safe, timely transitions and continuity with external agencies.

Job description

McLaren Health Care seeks a social work case manager to assess and intervene to help patients and families overcome social, economic and health-related barriers, coordinating discharge planning and linking them to appropriate resources.

You will triage within 24 hours, collaborate with the care team, coordinate community services (Meals on Wheels, home care, etc.), arrange family conferences, monitor readmission risk, and document plans in the EMR for safe transitions.