Social Worker - Case Management

Position Summary

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 read admissions.

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
• Leads a population of patients by service line and/or leads 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
• Care coordination
• Implementation or oversight of implementation of the transition plan
• Leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review
• Other related job tasks or responsibilities as assigned

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