MSW Discharge Planner & Care Coordinator

Mary Washington Healthcare Incorporated; Fredericksburg (VA); On-site; USD 47,000 - 70,000; Full time

Job summary

Mary Washington Healthcare Incorporated is seeking a Case Manager, Discharge (MSW) to organize and expedite discharge plans for medically complex cases. You will promote collaboration among care providers, identify discharge needs, and educate patients and families on community resources.

LMSW eligibility is noted, with opportunities to mentor staff and lead care coordination initiatives. The role emphasizes collaboration with clinical partners, intervention in abuse cases, and involvement in

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.
• Serves as a subject matter expert and functions as a resource person for care team members.
• Serves as a primary mentor for new social work Associates in the Care Coordination department and social work student interns.
• 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.
• Assists with audits and assessments of discharge planning documentation, as well as aides with complex care coordination situations that may arise.
• Partners with leadership to address concerns related to delays in discharge, barriers to discharge and trends noted.
• Serves as point of contact and resource for immediate post-discharge patient needs.
• 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.
• Participates in planning and implementing quality improvement activities.
• Performs other duties as assigned.

Skills

Critical thinking

Analytical skills

Communication

Multi-tasking

Education

Bachelor's degree in Social Work

Master's degree in Social Work

Tools

Windows-based programs

Email

Microsoft Word

Job description

Mary Washington Healthcare Incorporated is seeking a Case Manager, Discharge (MSW) to organize and expedite discharge plans for medically complex cases. You will promote collaboration among care providers, identify discharge needs, and educate patients and families on community resources.

LMSW eligibility is noted, with opportunities to mentor staff and lead care coordination initiatives. The role emphasizes collaboration with clinical partners, intervention in abuse cases, and involvement in