Social Worker Care Manager - Case Management - St. Francis Eastside - PRN

Essential Functions: Identifies and prioritizes patients in need of social services, using a holistic approach inclusive of biopsychosocial, functional, cultural, spiritual, and financial factors. Plans with the patient, caregivers and members of the healthcare team to maximize health care responses, quality and cost-effective outcomes. Monitors and revises the plan as indicated when patient condition changes. Completes all necessary documentation. Maintains, clear, concise, and timely documentation in the patient record to reflect the needs of the patients. Documentation will reflect plan of care to address post hospital care needs and resources and evidence of patient, family, or caregiver involvement in planning. Ensuring patient's and caregiver's treatment goals and preferences are incorporated into the transition of care planning and communicated to the multidisciplinary team. Follow standardized practices and process related to Advance Care Planning, Length of Stay management and readmission prevention. Supports denial prevention related to medical necessity through addressing/removing barriers to progression of care and participating in Interdisciplinary Discharge Rounds. Supports and promotes assertive, proactive care for patients, assisting in removing barriers related to achieving timely testing and treatment. Ensures resources are utilized appropriately and offering alternatives to acute care to the care team.

Education: Bachelor of Social Work (required)

Experience: 1 year of experience in clinical setting (required)3 year of experience in an acute care clinical setting (preferred) Ambulatory or post-acute, care coordination experience (preferred)