The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination.
The individual in this position has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission.
Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable readmissions.
This position integrates national standards for case management scope of services including:
Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Education provided to physicians, patients, families and caregivers •Leads a population of patients by service line and/or leads the team by being a resource to Tenet performance standards.
This individual’s responsibility will include the following activities:
- Complex psycho-social transition planning assessment and reassessment and intervention,
- Assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies,
- Care coordination, d) implementation or oversight of implementation of the transition plan,
- Leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review,
- Making appropriate referrals to other departments, g ) communicating with patients and families about the plan of care,
- Collaborating with physicians, office staff and ancillary departments, I) assuring patient education is completed to support post-acute needs ,
- Timely complete and concise documentation in Case Management system, k ) maintenance of accurate patient demographic and insurance information,
- Precepts new staff members and acts as a resource to all staff,
- Facilitates TEMPO as needed,
- Participates in department quality improvement initiatives, and
- Other duties as assigned.
Preferred: Two (2) years acute hospital experience.
Required: MSW based on license requirements of the state in which the Tenet Hospital operates.
Preferred: Accredited Case Manager (ACM).