Case Manager - Social Worker - Continuum of Care (Full Time)

POSITION SPECIFICS
Title: Case Manager – Social Worker 
FTE: 1.0 FTE (40 hours/week)
Schedule: Monday-Friday 8:00am-4:30pm. This position will float between our primary care clinics (Lodi, Spring Green, Plain, Prairie du Sac, Mazomanie), as well as help cover in Continuum of Care department, located at the main hospital campus in Prairie du Sac, WI.
Holiday Rotation: None 
Weekend Rotation: None
On Call Requirements: None
  
POSITION SUMMARY
The Case Manager-Social Worker coordinates and facilitates patient care activities to promote optimum and appropriate utilization of resources, improve continuity of care across the continuum, and to contribute to patient satisfaction and outcomes throughout the SPH organization (clinics and hospital). This position serves as a patient advocate, as a resource to patients/families and staff, and as a leader of the interdisciplinary team continuity of care/discharge planning/aftercare planning/resources. This position also serves as a liaison between the patient, staff, and physician to establish and implement a plan of care for each patient. The Case Manager-Social Worker conducts assessments of the biopsychosocial needs of patients, assists with identification of resources to assure successful outcomes, and facilitates expedited discharges across the continuum of care.
 
POSITION TECHNICAL RESPONSIBILITIES

1. Coordinate the integration of social services/case management functions into the patient care, discharge, and home planning processes with other SPH departments, external service organizations, agencies, healthcare facilities and providing resources to patients as needed.
2. Conduct concurrent medical record review using specific indicators and criteria as approved by medical staff, CMS, ACHC, and other state agencies. Acts as patient advocate, investigates and reports adverse occurrences, and performs staff education related to resource utilization, SDOH, discharge planning, and psychosocial aspects of healthcare delivery.
3. Complete assessment of all patients referred or identified as having complex psychosocial concerns and/or as needing discharge planning services, including data related to home environment, support systems, community agency involvement and psychosocial concerns to determine post-hospital/clinic visit needs.
4. Identify, assess, plan, implement, and evaluate individualized patient plan of care that includes clinic care, acute hospital care, discharge plan, transition to home or alternate site, and the use of community resources in conjunction with the multi-disciplinary care team, the patient and their family.
5. Address internal and external social, economic, emotional, medical, nursing and psychological needs, through referral, which will extend beyond the hospital/clinics
6. Provide support to patients and families to improve their understanding of an adjustment to the diagnosis to maximize benefits of medical intervention and enhance patient and/or family functioning.
7. Identify and works to eliminate barriers to successful and safe discharge/aftercare plan implementation.
8. Assess patients for potential needs in a timely manner and identifies those in need of case management intervention.
9. Document accurate assessments and interventions in patient’s electronic medical record in an effective and timely manner.
10. Mobilize resources and interviews, as needed, to achieve expected goal to assist in achieving desired clinical outcomes within the desired timeframe.
11. Identify patients with high risk or high-cost care, coordinate interventions, and facilitates appropriate discharge/aftercare plans. 
12. Provide post discharge/clinic visit case management to high risk populations.
13. Evaluate, plan, coordinate, review, and revise patient continuity of care/discharge plan/aftercare plan based on patient need in collaboration with medical staff and the multidisciplinary team.
14. Serve as a resource for patient/families, staff and providers, regarding legal/financial issues impacting patient’s care including advance directives, power of attorney, and guardianship. 
15. Work collaboratively with the care team and community agencies to assess, plan, and execute appropriate mental health and AODA services.
16. Coordinate care delivery processes and promptly intervenes in instances of delayed services or inappropriate utilization of resources.
17. Participate in multidisciplinary team meetings regarding the planning and implementation of patient care; facilitate communication and problem solving related to discharge planning
18. Coordinate and leads family conferences and/or multidisciplinary care conferences as needed.

• Required: Bachelor’s degree in Social Work
• Preferred: Master’s degree in Social Work

• Required: None  
• Preferred: Two or more years’ experience providing case management in a hospital or clinical setting

• Required:  State of Wisconsin License as a Social Worker
• Preferred: Clinical Social Worker (LCSW) License  

• Required: None
• Preferred:  Advanced Practice Social Worker (CAPSW) Certification. American Case Management Association (ACMA) Case Management certification 

1. Competitive health and dental insurance options
2. Flexible paid time off to balance work and life
3. Retirement plan with immediate vesting and employer match
4. Free membership to our state-of-the-art fitness facility
5. Generous tuition reimbursement
6. Employer provided life and disability insurance
7. Free parking at facility