Discharge Planning Case Manager - Social Work

Mary Washington Healthcare; Fredericksburg (VA); On-site; USD 42,000 - 69,000; Full time

Job summary

Mary Washington Healthcare in Fredericksburg, VA is seeking a dedicated Case Manager, Discharge (BSW) to organize and expedite treatment plans for medically complex cases and challenging social issues affecting hospital progression.

You will identify discharge needs, develop plans, educate patients and families, and collaborate with interdisciplinary teams to ensure safe transitions to post-acute care, including guardianship and end-of-life discussions.

Qualifications

• Bachelor's degree in Social Work required.
• Minimum one year experience in social work required.
• Experience with Windows based programs, e-mail, and Microsoft Word.
• 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 address delays in discharge and barriers to discharge.
• Provides intervention in cases of child/elder abuse/neglect and guardianship cases.
• Serves as a resource for 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.
• Performs other duties as assigned.

Skills

Critical thinking

Multi-tasking

Team collaboration

Education

Bachelor's degree in Social Work

Tools

Windows based programs

Email

Microsoft Word

Job description

Mary Washington Healthcare in Fredericksburg, VA is seeking a dedicated Case Manager, Discharge (BSW) to organize and expedite treatment plans for medically complex cases and challenging social issues affecting hospital progression.

You will identify discharge needs, develop plans, educate patients and families, and collaborate with interdisciplinary teams to ensure safe transitions to post-acute care, including guardianship and end-of-life discussions.