The Social Worker/Case Manager is responsible for managing patient assessments, discharge planning, and developing treatment plans within a multidisciplinary team. They collaborate with external providers and treatment teams to ensure continuity of care and facilitate smooth transitions between levels of care.
Requirements summary
Candidates must hold a Bachelor’s degree in social work, counseling psychology, or a related field, with a preference for one year of direct clinical experience in a psychiatric setting. Additional requirements include CPR certification and the successful completion of Crisis Prevention Intervention (CPI) training.
bachelor degreepostgraduate degreeCommunicationDocumentationNegotiationLeadershipOrganizational skillsTreatment planningCustomer relationsDischarge planningRisk assessmentCrisis interventionPatient advocacyPatient assessmentInterdisciplinary collaborationMental health supportCase managementPsychiatric care
Job description
Responsibilities
Position Summary
The Social Worker/Case Manager is responsible for managing the assessments and discharge planning activities offered to the patient, which may include assessing patients’ needs and compiling a treatment plan within a multidisciplinary team; planning and/or providing care, treatment, and services; collaboration and exchanging of information with the treatment team, external providers, collateral contacts, and/or managed care organizations; and implementation of the discharge planning process including completion of a thorough risk assessment and arranging for follow-up care and resources. The Social Worker/Case Manager will work closely with a Masters level clinician to provide oversight on assessments and clinical consultation as needed.
Qualifications
Education: Bachelor’s Degree from an accredited college or university in social work, counseling psychology, mental health or a related field. Enrollment in a Master’s Degree program in Social Work or Counseling Psychology preferred.
Experience
Preferred one (1) year direct clinical experience in a psychiatric or mental health setting. Experience in patient assessment, risk and safety assessments, treatment planning, community resources, family systems and communication, psychiatric diagnoses and effective treatments, and coordination with external review organizations preferred.
Additional
Requirements: CPR certification and successful completion of Crisis Prevention Intervention (CPI) training. CPI Training may be obtained during new hire orientation.
Qualifications
PRIMARY RESPONSIBILITIES Assessments Complete thorough assessments and documentation within the allotted timeframes.
Include patients’ behavior, criteria for hospitalization, and risk assessment in documentation.
Use the hospital criteria for continued evaluation for hospitalization and make appropriate recommendations for level of care upon discharge under the supervision of a Master’s level clinician.
Complete initial discharge planning and risk assessments under the supervision of a Master’s level clinician.
Integrate assessment information with the attending physician’s initial treatment plan and compile a Master Treatment Plan with individualized, measurable, and observable problems, interventions, and short-term goals.
Update Master Treatment Plan integrating the patient’s progress, obtained collateral information, and identified resources.
Assess and document patient’s ongoing progress including progress towards treatment goals and make changes to the identified plan for discharge/safety as appropriate.
Complete a Chemical Dependency Assessment as needed under the supervision of a Master’s level clinician.
Case Management Engage, collaborate, and problem-solve with patients, families, treatment team members and community providers regarding patient status and progress towards discharge.
Ensure/assist that the patient attends the appropriate level of care or program as indicated on the treatment plan or as needed when there are changes in the patient’s status.
Interface with the staff of the appropriate level of care to facilitate a smooth transition at the time of transfer.
Maintain necessary documentation of all services and the quality of care.
Communicate and enforce the documentation requirements with all levels of staff to meet accreditation and certification body regulations.
Maintain knowledge of a variety of resources to assist in patient care.
Promote an effective use of resources for patients, customers and the facility with sensitivity to the cost of health care.
Follow through on case management tasks such as discharge planning, documentation, and auditing chart compliance.
Ensure that patient’s rights are upheld.
Advocate for the lowest level of care consistent with patient needs.
Function as a resource for patient/families/significant others.
Coordinate high risk cases requiring reporting and coordination/communication with other involved agencies.
Facilitate family meetings with patients, support systems, and service providers (if applicable) to enable appropriate discharge with safety and crisis plans in place.
Use current systems and materials to provide "hand off" communication.
Discharge Planning Coordinate discharge plans with the patient/family/significant other that were identified by the treatment team.
Provide, monitor and document discharge planning activities including but not limited to identification of discharge planning needs, involvement of patient, family and significant others as appropriate, completing referrals for aftercare follow-up, coordination of referrals to other agencies including transmission of necessary information.
Identify and provide appropriate resources to assist with potential risk factors and the patient’s identified needs.
Organize the use of resources to keep the patient as close to home as possible, provide liaison to aftercare providers and follow up after discharge to ensure efficacy of the discharge plans.
Treatment Planning Provide support and assistance to the patient and the patient’s support system.
Formulate an initial discharge plan from information gathered during the assessment process.
Planning/assist in an episode of care to identify services that will be provided if the patient is moved to a greater or less intensive level of care depending on the needs of the case.
Communicate with attending practitioner and treatment coordinator, and other providers of service, to assure continuity of care and expedite the flow of services and transition between levels of care.
Provide feedback to the attending practitioner and treatment team members concerning continuing certification of days/services.
Knowledge of and Adherence to Standards for the Care of Specific Developmental Stages Specific Standards for the Care of Adolescent Patients Ages 13 through 18 Maintain knowledge of the Adolescent Program rules, protocols and handbooks guidelines.
Assess patients for behaviors consistent with the developmental stages and makes note of any deviations in behavior.
Recognize acting out behavior of adolescent specific age group and set appropriate limits in clear, concise, behavioral and non-judgmental terms based on the age of the patient.
Demonstrate an awareness of learning disabilities and translates treatment/program expectations to the learning disabled adolescent.
Maintain knowledge of the different systems of care and resources available through those systems of care including: Child Protective Services, Juvenile Justice Dept., Adoption Services, Foster Care services, School Services, and EPSDT.
Relate to adolescent patients in an age appropriate manner.
Act as a resource to other staff in regard to the Adolescent Patient Programs.
Facilitate family meetings with adolescents, caregivers, and service providers (if applicable) to enable appropriate discharge with safety and crisis plans in place.
Specific Standards for the Care of Adult Patients Ages 19 through 64 Gather information from the patient, family, outpatient provider (if applicable), and interdisciplinary team and use judgments based on knowledge of adult behaviors in treatment planning and interventions.
Recognize behaviors and set appropriate limits in clear, concise, behaviors and non-judgmental terms.
Maintain current knowledge of the Adult Program rules, protocols and handbook guidelines.
Maintain knowledge of the different systems of care and resources available through those systems of care including: County funded services, Probation and/or Parole, Conserved patients, privately insured services, services for undomiciled/ at risk populations.
Facilitate meetings with patients, caregivers, and service providers (if applicable) to enable appropriate discharge with safety and crisis plans in place.
Utilize theoretical concepts to guide the effective practice of adult care within Specific Standards of care for this age group.
Specific Standards for the Care of Geriatric Patients Ages 65 and older Maintain knowledge of the developmental tasks and sociological theories of aging.
Utilize theoretical concepts to guide the effective practice of gerontological health care and behavioral care Gather the appropriate information from the patient, family and interdisciplinary team and use therapeutic judgments based on knowledge of gerontological health/behavioral care practices to develop a comprehensive plan of care.
Utilize interventions based on gerontological theory to restore patient’s functional capabilities and to prevent complications and excess disability.
Maintain knowledge of the different systems of care and resources available through those systems of care including: County funded services, Probation and/or Parole, Conserved patients, privately insured services, services for undomiciled/at risk populations, and geriatric services.
Facilitate meetings with patients, caregivers, and service providers (if applicable) to enable appropriate discharge with safety and crisis plans in place.
Maintain knowledge of treatments, medications and side effects of such in the geriatric age group.
Specific Standards for the Care of Chemically Dependent Patients Assesses patient needs as related to chemical dependency and document the plan of care from the admission through discharge.
Collaborate with other chemical dependency staff professionals in planning for discharge and follow-up care.
Maintain knowledge of the different systems of care and resources available through those systems of care including: Sober living environments, rehabilitation centers, county funded services, Probation and/or Parole services, privately insured services, and services for undomiciled/at risk populations.
Maintain an awareness of how personal issues relating the co-dependency can impact work performance/relationships.
Recognize and establish limits on medication-seeking behaviors.
Specific Standards of the Care of Culturally/Spiritually Diverse Patients Recognize that everyone is uniquely multicultural (belonging to many subgroups, which define the person’s belief system, behavior, language work ethic, etc.).
Show an awareness of differences in communication styles and cultural and spiritual values and work ethics.
Show an ability to refrain from assuming that everyone is “just like me” or judging others by one’s own codes of behaviors.
Demonstrate an awareness of one’s own values, beliefs, stereotypes and bias and how they dictate attitudes and behavior.
Show an understanding of how cultural rules of behavior impacts how we perceive others and how they perceive us.
Demonstrate a willingness to modify behavior accordingly.
RELATIONSHIP WITH OTHERS Functions effectively as a member of the team, using tact, sensitivity, sound judgment and a professional attitude when relating to patients, families, visitors, and co-workers at all times.
Addresses patients, visitors, physicians, and co-workers in a pleasant and respectful manner and maintains favorable working relationships.
Responds to patients with empathy and positive interpersonal skills.
Demonstrates flexibility and assumes added tasks when department needs change.
Is receptive to feedback and acts on feedback given.
PERFORMANCE IMPROVEMENT Understands his/her role in the Performance Improvement process and participates as required.
OTHER PERFORMANCE CRITERIA Attends all mandatory facility in-services and staff development activities as scheduled.
Performs other duties as assigned.
CUSTOMER SERVICE Demonstrates a service focus in all interactions.
Demonstrates proper etiquette by acknowledging patients, guests, employees, etc., promptly and by answering the phone properly (salutation, identify self and department, and within three rings).
Keeps customers informed by explaining procedures and updating them on changes, or delays in procedure.
Offers an explanation of reasons behind policies, procedures, and instructions (when possible).
Responds to information requests about the hospital and/or its programs within 24 hours to both community and professional external customers.
MISCELLANEOUS Assures department is maintained in clean and safe manner.
Complies with established measures for infection control, OSHA regulations and risk management.
Follows all facility, departmental and personnel policies and procedures.
Complies with the Employee Code of Ethics.
Attends regular staff meetings and department required functions.
ATTENDANCE AND RELIABILITY Reports to work on time for assigned shifts.
Maintains a good attendance record consistent with the hospital attendance policy.
Note
The essential job functions of this position are not limited to the duties listed above. KNOWLEDGE, SKILLS, AND ABILITIES THIS SECTION DESCRIBES WHAT KNOWLEDGE, SKILLS AND ABILITIES AN EMPLOYEE IN THIS POSITION SHOULD CURRENTLY POSSESS. THIS LIST MAY NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED FOR THIS POSITION. Knowledge of case management techniques. Knowledge of patient assessment, family motivating treatment planning techniques. Knowledge of external review organizations (i.e. managed care, Medicare, Medicaid, state gate keep for Medicaid). Knowledge of patient’s rights, advanced directives, adult and child abuse laws, and emergency detention. Knowledge of complex patient care planning. Knowledge and utilization of crisis intervention techniques. Knowledge of payer resources and financial planning. Excellent leadership and negotiation skills. Excellent customer relations skills. Excellent organizational and interpersonal communication skills. Skill in interacting with multiple individuals with diversified roles and perspectives. Skill in organizing and prioritizing workloads to meet deadlines. Skill in telephone etiquette and paging procedures. Effective oral and written communication skills. Ability to communicate effectively both verbally and in writing. Ability to handle conflicting situations. Ability to focus on details in a busy environment. Ability to assess various situations/circumstances and develop a thorough case study. Ability to operate in an unstructured environment, orchestrate a myriad of activities and to manage multiple priorities within complex systems. Ability to tolerate ambiguity, uncertainty, and change. Ability to work at a rapid pace. Ability to communicate effectively with patients and co-workers. Ability to adhere to safety policies and procedures. Ability to use good judgment and to maintain confidentiality of information. Ability to work as a team player. Ability to demonstrate tact, resourcefulness, patience and dedication. Ability to accept direction and adhere to policies and procedures. Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric). Ability to work in a fast-paced environment. Ability to meet corporate deadlines. Ability to react calmly and effectively in emergency situations. PHYSICAL, MENTAL, AND SPECIAL DEMANDS THIS SECTION DESCRIBES HOW AN EMPLOYEE IN THIS POSITION CURRENTLY PERFORMS THE FUNCTIONS OF THIS POSITION. MODIFICATIONS TO THE MANNER IN WHICH THIS JOB MAY BE PERFORMED WILL BE REVIEWED ON A CASE BY CASE BASIS. Ability to stand, or walk up to six hours, sit for up to two hours. Ability to spend 20% of the workday outdoors in temperatures varying from 30˚-100˚F and 80% of the workday indoors in temperatures varying from 60˚-85˚F. Ability to occasionally push/pull wheeled carts from 200lbs. (i.e. crash carts, patient on stretchers or in wheelchairs). Ability to frequently lift and carry up to 10 pounds; occasionally lift and carry up to 100lbs. Ability to see well enough to read written materials. Ability to discern a variety of odors. Ability to handle hazardous/infectious waste on an occasional basis. Ability to work in an environment where the noise level is frequently high; where chemicals are frequently used in cleaning; where mechanical and electrical hazards may occasionally be present; and where dust, mist and stream are frequently generated in housekeeping tasks. Ability to respond to exposure to blood and bodily fluids.
Machines,
TOOLS,
Equipment,
AND
OTHER
WORK
AIDES: THIS SECTION DESCRIBES THOSE MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES AN EMPLOYEE IN THIS POSITION MUST BE ABLE TO USE. Computer, email, and bed board systems. Telephone and paging system. Copy and fax machines. Medical Records. Policies, procedures, plans and program manuals.
