Social Work Care Manager

**Description** **All the benefits and perks you need for you and your family:** Benefits from Day One Paid Days Off from Day One Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense) **Our promise to you:** Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that **together** we are even better. **Schedule:** Full Time **Shift** : 8am-5pm-40 hours a week, accept 4 weekend shifts in a six week period. Possible holidays. **The community you’ll be caring for:** AdventHealth Kissimmee is a 242-bed community-focused hospital Conveniently located near Walt Disney World The team is here is dedicated to bringing mission-focused, faith-based care to residents and visitors of Osceola and Orange Counties AdventHealth Kissimmee has recently expanded our existing tower by 3-floors and 80-beds, including new ancillary spaces such as Inpatient Rehab, Inpatient Dialysis, Laboratory, and Imaging services.   **The role you’ll contribute:** The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Social Worker is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. **The value you’ll bring to the team:** Psychosocial Assessment and Interventions Assesses patient's and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, assisting those coping with adjusting to significant life transitions Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs Serves as a resource to provide information and intervention related to treatment decisions, terminal illnesses and end-of-life issues Provides grief counseling and crisis intervention skills Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system Provides de-escalation services for patient/family as appropriate Provide Motivational Interview techniques for patients with substance use and addictive disorders Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers Receives referrals for psychosocial complex needs from the health care team. Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate. Provides consult services for patients who may possibly lack decision making capacity. Follows the guardianship (temporary/ permanent) policies and procedures and coordinates with Care Management leadership throughout the process. Provides consult services for foster care and adoptions. Assists the health care team in the patient assessments and placements for mental health services. Facilitates full team discussion including patient and family when ethical dilemmas arise. Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation. Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes. Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team. Incorporate clinical, social and financial factors into the transition of care plan. Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care. Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement. **Qualifications** **The expertise and experiences you'll need to succeed:** **EDUCATION AND EXPERIENCE REQUIRED:** Masters in Social Work (MSW) Minimum three (3) years experience in hospital/medical social work **EDUCATION AND EXPERIENCE PREFERRED:** Care Management discharge planning experience Knowledge of state and federal guidelines pertinent to care management **PREFERRED:** Licensed Clinical Social Worker (LCSW) ACM/CCM certification This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. **Category:** Case Management **Organization:** AdventHealth Kissimmee **Schedule:** 1 - Day **Shift:** AdventHealth Kissimmee **Req ID:** 23010665 We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.