Nuvance Health Careers

Description

Summary:

The Ambulatory Clinical Social Worker, Care Management collaborates with patients of the care management team to develop treatment plans that assist patients and their families as they deal with emotional, financial, social and physical effects of a disease or multiple chronic conditions. This professional is part of an interdisciplinary team, including the patient/family, physicians, nurses, therapists, and payers who work to ensure that patient progress in the acute episode of care through post discharge is quality-driven, efficient, and cost-effective.

Responsibilities:

1. Supports patients and their families to ensure they can function to the best of their ability and maintain a level of optimal health according to their disease state. Interacts with patients, famililes, healthcare professionals and community and state agencies and serves as a liaison between hospital and community agencies or facilitates that exchange of clinical and referral information.
2. Interacts with various entities in the pateint's medical neighborhood to arrange all aspects of care for the patient including, but not limited to, durable medical equipment, pharmacy, nursing, rehabilitation, or other services to ensure patients receive quality servies in a timely, cost-effective manner.Modifies treatment plans to comply with changes in patients or their support system status and needs.
3. Ability to Function in the Transition of Care Role as necessary
4. Assesses patients at the point of disposition to optimize patient centric plan of care. Identifies high-risk patients from a psychosocial/financial perspective, assesses the psychological needs of patients and families, and provides information, support, counseling, care management, and referrals to appropriate resources.
5. Collaborates closely and receives referrals from the RN care manager and care team to ensure patient needs are met and care delivery is coordinated across the continuum.
6. The care team will seek the expertise of the social worker to address psychosocial patient-care issues, develop and implement a complex patient transition/discharge plan and ensure that patients are assisted to achieve the highest level of function and return to the least restrictive environment post-hospitlalization. Monitors, evaluates and records client progress according to measurable goals described in treatment and care plan.
7. Maintains a keen knowledge in areas such as insurance benefit reimbursement, community resources, and all ancillary clinical services to meet the needs of internal and external clients.
8. Initiates and/or monitors completeness, accuracy and timeliness of all documentation as required. Ensures adherence to quality standards.
9. Performs medical record review to assist with implementing discharge plan in absence of RN care manager and reports potential risk or quality management issues in accordance with the medical record review.
10. Understands and complies with regulations and recommendations of outside regulatory bodies and adheres to patient bill of rights, social worker code of ethics and professional responsibilities.
11. Demonstrates capability to adapt and change work processes and role responsibilities and activities to improve service delivery.
12. Participates in professional development, research and performance improvement or quality activites as assigned.
13. Demonstrates ability to work autonomously and be directly accountable for results. Applies customer-focused interpersonal skills to interact effectively with practitioners, the interdisciplinary healthcare team, community agencies, patients and families with diverse opinions, values, religious and cultural beliefs.
14. Fulfills all compliance responsibilities related to position, performs all other duties as assigned.
15. Performs other duties as assigned.

Education: MASTER'S LVL DGRE

Other Information:

Required: Requires ability to travel and manage fluctuating work hours. Current valid driver’s license and access to a good working vehicle are required for appropriate home visits Demonstrates excellent listening, verbal, written and critical thinking skills
Minimum Experience: one year
Desired: Working knowledge of insurance coverage. Experience in ambulatory/managed care Prior case/care management experience

Working Conditions:

Manual: Some manual skills/motor coord & finger dexterity

Occupational: Little or no potential for occupational risk

Physical Effort: Medium to Heavy effort. May exert up to 35 lbs. force

Physical Environment: Some exposure to dirt, odors, noise, human waste, etc.

Credentials:LCSW

Company: Nuvance Health

Org Unit: 1817

Department: Care Mgmt

Exempt: Yes

Salary Range: $41.00 - $76.16 Hourly