Discharge Planning & Care Coordination Case Manager (BSW)

Mary Washington Healthcare; United States; On-site; USD 42,000 - 69,000; Full time

Job summary

Mary Washington Healthcare is seeking a Case Manager, Discharge (BSW) to organize and expedite a treatment plan of care for medically complex patients and challenging social issues. You will identify discharge needs, develop plans, and educate patients and families while coordinating with clinical partners.

You will also intervene in cases of abuse/neglect, participate in end-of-life discussions, and lead comprehensive care planning with an interdisciplinary team.

Qualifications

• Bachelor’s degree in Social Work required.
• A minimum of one year experience in social work required.
• Experience with computer technology, specifically Windows based programs, e-mail, and Microsoft Word required.
• Experience in a healthcare field preferred.
• Case Management Certification strongly desired.

Responsibilities

• Coordinates care of patients with clinical partners; helps patients advance towards realistic and desirable outcomes.
• Assesses long term and/or future patient care needs by identifying probable changes in level of independence or functional quality.
• Communicates activity status updates regarding treatment plan with clinical partners.
• Provides information and education on community resources to patient and their families.
• Develops, coordinates, and communicates discharge plans with the patient, family members and care team for medically complex and difficult social issues related to hospital progression.
• Documents assessment and overall discharge plan in medical record.
• Collaborates with leadership to appropriately address concerns related to delays in discharge, barriers to discharge and trends noted.
• Provides intervention in cases of child/elder abuse/neglect and guardianship cases.
• Serves as a resource person related to treatment decisions surrounding end of life and Medical Power of Attorney.
• Facilitates meetings and comprehensive care planning with interdisciplinary team.
• Delegates work to support team members.
• Utilizes post-acute care facilities for safe and effective discharge planning.
• Collaborates with contracted partners associated with financial needs to facilitate post-acute facility placement.
• Conducts psychosocial assessment as needed for development of appropriate discharge plan for medically complex and difficult social issues.

Education

Bachelor’s degree in Social Work

Tools

Windows

Email

Microsoft Word

Job description

Mary Washington Healthcare is seeking a Case Manager, Discharge (BSW) to organize and expedite a treatment plan of care for medically complex patients and challenging social issues. You will identify discharge needs, develop plans, and educate patients and families while coordinating with clinical partners.

You will also intervene in cases of abuse/neglect, participate in end-of-life discussions, and lead comprehensive care planning with an interdisciplinary team.