Our compassionate team provides a wide range of inpatient and outpatient services, including acute care rehabilitation, joint replacement & spinal surgery, neurosurgery, ICU, Telemetry, step-down care, skilled nursing, as well as outpatient therapy, hand and lymphedema clinics.

Roles And Responsibilities:

The individual in this position 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 to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and interventions 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 sequenced and provided at the appropriate level of care.
• Compliance with state and federal regulatory requirements, TJC accreditation standards and our policy
• Education provided to physicians, patients, families and caregivers
• Precepts new staff members and acts as resource to all staff.
• Participates in department Quality Improvement initiatives, one committee participation and/or major projects as assigned

This individual's responsibility will include the following activities:
a) Complex psycho-social transition planning assessment and reassessment and intervention,
b) Assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies,
c) Care coordination,
d) Implementation or oversight of implementation of the transition plan,
e) Leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review,
f) Making appropriate referrals to other departments,
g) Communicating with patients and families about the plan of care,
h) Collaborating with physicians, office staff and ancillary departments,
i) Assuring patient education is completed to support post-acute needs ,
j) Timely complete and concise documentation in Case Management documentation system,
k) Maintenance of accurate patient demographic and insurance information,
l) Other duties as assigned.

Must Haves:

Required qualifications include CA LCSW. Must be currently licensed, certified, or registered to practice profession as required by law or regulation in state of practice or policy. Active license for state(s) covered.

Nice to haves:
Accredited Case Manager (ACM).
Minimum of two years acute hospital experience preferred.