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Complex Inpatient Medical Social Worker

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Advocate Health Care

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Location:
United States

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Category:
Nursing

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Contract Type:
Not provided

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Salary:

33.05 - 49.60 USD / Hour
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Job Description:

Provides care management/social work services to Complex patients, families, and individuals. Implements targeted interventions and patient-family centered care plans to achieve optimal health outcomes. Collaborates and negotiates effectively with socially complex patients, family and the clinical team. Provides advanced care management guidance and mentorship to frontline care management team members. Serves as a leader in the multi-disciplinary health care team to develop safe and timely coordination of care.

Job Responsibility:

  • Provides care management/social work services to Complex patients, families, and individuals including perming thorough patient psychosocial assessments, screening, determination of needs evaluation, appropriate interventions and follow up, and discharge planning
  • Implements targeted interventions and patient-family centered care plans to achieve optimal health outcomes
  • Collaborates and negotiates effectively with socially complex patients, family and the clinical team while striving to achieve patient and organizational goals regarding care needs, choices, and satisfaction during discharge planning and care transitions
  • Provide continuity of care and discharge planning services for socially complex patients compliant with regulatory standards
  • Provides advanced care management guidance and mentorship to frontline care management team members fostering a culture of excellence and continuous improvement
  • Initiates internal and external referrals to ensure timely progression of care and transitions for socially complex patients
  • Documents discharge planning interventions and utilization review activity according to department and organization standards in a timely manner
  • Advocates for patients and their families to ensure their voices are heard and their needs are met within the healthcare system while optimizing the utilization of hospital resources ensuring cost-effective care delivery and adherence to regulatory guidelines
  • Communicates effectively with the healthcare team regarding socially complex patients
  • Serves as a leader of the multidisciplinary rounds and work closely with clinical team members, hospital departments and ancillary services to identify and resolve barriers to discharge, expedite care delivery to avoid delays in timely service provision, and implement and report on care coordination and discharge planning
  • As an expert in care management of socially complex patients, collaborates and leads discussions with managers, physicians, medical directors, advisory groups, and treatment teams for issues related to physician practices and best practices for patient care plans
  • Develops and maintains productive relationships with community-based agencies, particularly those serving socially complex patients
  • Serves as a leader in the multi-disciplinary health care team to develop safe and timely coordination of care including but not limited to post-acute placement, palliative/hospice service lines, medical equipment, home healthcare, outpatient follow up, mental health resources, and other community resources
  • Maintains up-to-date knowledge of community resources, legislation, and regulations impacting health care delivery and educating patients and families on these issues as appropriate
  • Manages the progression of patients stay with the goal of optimizing the LOS and ensuring appropriateness of assigned Level of Care
  • Manages the patient’s care across the continuum to decrease unnecessary readmissions
  • Manages and coordinates patient care within an ACO environment to help facilitate patient outcomes through in network care coordination
  • Participates in the orientation of new staff and/or education of social work students
  • Aggregates, analyzes, interprets and reports data on patient outcomes and resource utilization

Requirements:

  • Master’s Degree in Social Work
  • LSW license issued by the State in which the team member practices (WI & IL Divisions)
  • Accredited Case Manger SW (ACM-SW) certification issued by the American Case Management Association (ACM) needs to be obtained within 2 years, or Certified Case Manager (CCM) issued by the Commission for Case Manager Certification (CCMC) needs to be obtained within 2 years, or Certified Social Worker in Health Care (C-SWHC) issued by National Association of Social Workers to be obtained within 2 years
  • 3 years of hospital care management experience
  • Ability to prioritize and organize work
  • Effective communication skills
  • Utilization of critical thinking and timely decision making
  • Ability to navigate the electronic health record
  • Basic utilization of MS Office products
  • Knowledge of Medicare A and B guidelines
  • Knowledge of managed care program requirements/implications
  • Ability to apply elements of utilization management programs
  • Must be able to sit up to approximately 50 percent of the workday
  • stand and walk for the equivalent of several blocks at a time
  • Must lift up to 10 lbs. continuously, up to 20 lbs. frequently, and up to 50 lbs. occasionally
  • Manual dexterity required for operation computer and calculator
  • Visual acuity required for facilitating review of written documents/computer screens, medical records, and to record information accurately
  • Clear verbal communications and hearing acuity required for receiving instructions and converse on standard telephone
  • Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone
What we offer:
  • Paid Time Off programs
  • Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
  • Flexible Spending Accounts for eligible health care and dependent care expenses
  • Family benefits such as adoption assistance and paid parental leave
  • Defined contribution retirement plans with employer match and other financial wellness programs
  • Educational Assistance Program

Additional Information:

Job Posted:
February 20, 2026

Employment Type:
Fulltime
Work Type:
On-site work
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