SW Transitions And Care Coordinator Full Time

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); On-site; USD 60,000 - 72,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC seeks a CAP Case Manager to assess, plan, coordinate, and follow up care for beneficiaries, linking with medical, social, and behavioral services to promote whole-person wellbeing.

The role emphasizes transitions, readmission reduction, and community resource connections. Requires MSW; CCM preferred; 1 year medical social work experience; strong communication and independence.

Qualifications

• MSW required; CCM preferred (certificate).
• 1 year of medical social work, case management, disease management transitions coordination, or care coordination.
• Fluent in English; able to read, write, and communicate effectively.

Responsibilities

• Provide case management and care coordination to assigned CAP caseload to maximize client-centered outcomes.
• Coordinate Money Follows the Person Transitions and Community Transitions to reduce acute length of stay and avoid readmissions.
• Perform comprehensive interdisciplinary needs assessments and formulate person-centered care plans.
• Conduct follow-up visits and support after discharge to reduce readmission risk.
• Provide referrals and linkage to medical, behavioral, social, and other programs; document through eCAP.

Skills

Excellent communication

Independent work

Case management

Interpersonal skills

Education

Master’s degree in Social Work (MSW)

Job description

FacilityCape Fear Valley Medical CenterLocationFayetteville, North CarolinaDepartmentCommunity Alternatives Program ServicesJob FamilyProfessionalWork ShiftDays (United States of America)SummaryProvides CAP case management that consists of assessing, care planning, referral and linkage, monitoring and regular follow up. Case managers will identify needed medical, social, environmental, financial, and emotional interventions. Responsible for overseeing the maintenance of community integration while ensuring the beneficiary’s health, safety and wellbeing. Consistently communicate with local, region and state resources to ensure mental, spiritual, medical and social needs are met. Required to provide crisis interventions to encourage adherence to long term medical and mental health care.Major Job FunctionsThe following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:Provides case management and care coordination activities to assigned caseload in a manner that maximizes patient satisfaction, provider satisfaction and client centered outcomesCoordinates Money Follows the Person Transitions as well as Community Transitions such that the length of stay in acute care, or other qualifying level of care is reduced, appropriate supports are put in place, and readmissions are avoidedPerforms comprehensive interdisciplinary needs assessments for the assigned CAP beneficiaries monthlyFormulates the plan of care in collaboration with the beneficiary and support persons with the service plan specifying person-centered goals, objectives, and formal as well as informal support services to address identified medical and functional care needsProvides follow-up visits and/or other support to beneficiaries who have been discharged from acute care or SNF to reduce the possibility of readmissionProvides referral and linkage activities to connect a beneficiary or caregiver with medical, behavioral, social, and other programs, services and supports to mitigate identified needs and achieve whole person-centered goalsCompletes documentation via eCAP internet- based programResponsible for SBARR communication with acute care staff when CAP beneficiaries are hospitalized and performs as a liaison for discharge planning as neededDevelop resources to serve the assigned population through grants, networking with outside agencies and other departments within the Health System and through other approved meansOther duties as assignedMinimum QualificationsThe following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:Education and Formal Training:Master’s degree in Social Work (MSW) requiredNational Certification in Case Management or Licensed Clinical Social Worker preferredMaintain State requirements for population served when performing CAP/DA, CAP/C, CAP/Choice or MFP transitions or case management requiredWork Experience:1 year previous experience in medical social work, case management, disease management transitions coordination, or care coordination requiredKnowledge, Skills, and Abilities Required:Proficiency in reading, writing, and speaking the English languageAbility to work with high degree of independence, demonstrating personal accountability, responsibility for performance improvement and high professional growthPositive interpersonal skills with excellent communication, problem solving and negotiation skillsStrong organizational skills, critical thinking skills, and the ability to appropriately prioritize direct case management, patient/family support and other dutiesKnowledge of Erickson’s developmental model and ability to demonstrate age specific interventionsKnowledgeable and sensitive to the psychosocial spiritual and cultural needs of individualsArticulate orally and in written communication and ability to make accommodations for literacy and comprehension levelsPhysical Requirements:Ability to use own transportation to make home visits and to carry out duties away from the officeVisual acuity to see and read medical records documents, computer screens and computer printoutsSpeech and auditory abilities are required to allow for effective communicationAmbulate, climb stairs and push or pull wheelchair patients at timesAbility to lift, load/unload client care supplies/equipment up to 30 poundsPosition may involve contact with blood or potentially infectious materialRequired Licenses and CertificationsCCM - Commission For Case Manager CertificationCape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity