Social Work Case Manager Part Time Days 

AdventHealth Daytona Beach

Location Address: Daytona Beach, FL

Top Reasons to Work at AdventHealth Daytona Beach

Health Insurance Coverage

Faith-based organization

Great benefits such as: Educational Reimbursement

Career growth and advancement potential

Low cost of living near sunny beaches

Work Hours/Shift:

 PT/Days

You Will Be Responsible For:

• Psychosocial Assessment and Interventions

• Assesses patient’s and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, assisting those coping with adjusting to significant life transitions
• Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs
• Serves as a resource to provide information and intervention related to treatment decisions, terminal illnesses and end-of-life issues
• Provides grief counseling and crisis intervention skills
• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system
• Provides de-escalation services for patient/family as appropriate
• Provide Motivational Interview techniques for patients with substance use and addictive disorders
• Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention
• Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis
• Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers

• Receives referrals for psychosocial complex needs from the health care team.
• Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.
• Provides consult services for patients who may possibly lack decision making capacity.  Follows the guardianship (temporary/ permanent) policies and procedures and coordinates with Care Management leadership throughout the process.
• Provides consult services for foster care and adoptions.
• Assists the health care team in the patient assessments and placements for mental health services.
• Facilitates full team discussion including patient and family when ethical dilemmas arise.
• Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed 
• Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.
• Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes.
• Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.
• Incorporate clinical, social and financial factors into the transition of care plan.
• Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care. 
• Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
• Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
• Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans. 
• Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient’s readmission risk scores and coordinating readmission mitigation interventions.
• Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
• Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
• Escalates issues barriers to appropriate level of Care Management leadership
• Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
• Facilitates patient care conferences with multidisciplinary team as needed.
• Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
• Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients
• Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
• Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
• Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care
• Ensures reassessment of discharge needs provided anytime a patient’s condition changes and/or the circumstances impacting the provision of post-hospital care changes.
• Ensures patient notifications are provided and documented in a timely manner for compliance:  Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
• Communicate with patient/family the possible need to pay for services out of pocket.
• Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care.
• Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
• Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
• Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
• Participates in department and hospital Performance Improvement activities.
• Provides necessary patient care coverage and assistance with other duties as assigned when needed.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
• Participates in facility and department regulatory and certification preparations.
• Social Work Care Manager serves as a preceptor
• Social Work Care Manager participates in department education (bulletin or presentation) with topic and content approved by Facility CM Director

What you will need:

EDUCATION AND EXPERIENCE REQUIRED:

• Bachelor's in Social Work with health care related Masters or MSW
• Minimum three (3) years experience in hospital/medical social work

EDUCATION AND EXPERIENCE PREFERRED:

• Masters in Social Work
• Care Management discharge planning experience
• Knowledge of state and federal guidelines pertinent to care management

KNOWLEDGE AND SKILLS REQUIRED:

• Excellent interpersonal communication and negotiation skills
• Critical thinking and problem-solving skills
• Psychosocial assessment skills
• Customer service skills
• Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change
• Effective organizational skills
• Computer proficiency with Outlook e-mail and electronic medical records
• Flexible in a complex and changing healthcare environment
• Understanding of pre-acute and post-acute venues of care and post-acute community resources
• Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources
• Strong interview, assessment, and organizational skills
• Leadership skills
• Data analysis skills