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; and
• Education provided to physicians, patients, families, and caregivers.

Responsibilities

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
• 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
• Communicating with patients and families about the plan of care
• Collaborating with physicians, office staff and ancillary departments
• Assuring 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
• Other duties as assigned.

Education

Required: Bachelor of Social Work.

Experience

Preferred: 1 year of acute hospital experience.

Certification

Required: BSW. 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.

Preferred: Accredited Case Manager (ACM)

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.