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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; and Leads a population of patients by service line and/or leads the team by being a resource to Tenet performance standards.
Job Responsibility:
Facilitate care along a continuum through effective resource coordination
Assess the patient for transition needs including identifying and assessing patients at risk for readmission
Conduct complex psycho-social assessment and intervention to promote timely throughput, safe discharge, and prevent avoidable readmissions
Integrate 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
Lead a population of patients by service line and/or lead the team by being a resource to Tenet performance standards
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
Implementation or oversight of implementation of the transition plan
Lead and/or facilitate multi-disciplinary patient care conferences including Complex Case Review
Make appropriate referrals to other departments
Communicate with patients and families about the plan of care
Collaborate with physicians, office staff, and ancillary departments
Assure patient education is completed to support post-acute needs
Timely complete and concise documentation in Case Management system
Maintenance of accurate patient demographic and insurance information
Precept new staff members and act as a resource to all staff
Facilitate TEMPO as needed
Participate in department quality improvement initiatives
Requirements:
Master's of Social Work
Must be currently licensed or license eligible to practice as a LICSW, LCSW, or LMHC in adherence with state regulatory requirements