Incumbent serves as an Outpatient/Inpatient Social Worker Case Manager for TCRHCC and Sacred Peaks Healthcare Center (SPHC) and is responsible for direct supervision and supportive contact for the specific group of identified high-risk patients. The Social Worker Case Manager is responsible for designing and managing a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency. The Social Worker Case Manager is responsible for assessment, service planning, and resource acquisition, monitoring progress and initiating and responding to emerging client needs. The Social Worker Case Manager will link the client with Community Social Service providers, health care providers, substance abuse, and mental health providers to achieve specific goals. The Social Worker Case Manager will have experience working with culturally diverse low income populations having multiple barriers to self-sufficiency such as: illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. The Social Worker Case Manager will work with a multidisciplinary team within the service delivery setting. The Social Worker Case Manager will be committed to Case Management Services and have some assignments with Purchased and Referred Care (PRC) formally known as Contract Health Services, providing assistance with the PRC Case Specialist. The Social Worker Case Manager will be responsible to the Director of Case Care Coordination.
- Coordination of service specific assessments, service planning and enrollment
- Works with all facets of the Case Management continuum, i.e., social support, alternate resources, community referrals, discharge planning, Nursing Home/Skilled Nursing Placement and resource utilization.
- Comprehensive and client centered service planning and coordination
- Works proactively with the established RN Case Managers/ Social Workers of TCRHCC as a team member for care coordination of the patient populations served by TCRHCC
- Resource acquisition facilitated referrals and linkages
- Consistent and on-going case consultation with all direct service providers
- Developing and maintaining internal and external resource relationship
- Service monitoring and following up to ensure continuity of care and updating of the client service plan
- Identifies patient through consultation and high risk diagnoses, i.e. COPD, CHF, DM
- Assists with the development of department reports, policy/procedures manuals, and program objectives
- Assists with special projects as assigned
- Conducts system and procedural efficiency evaluation to determine progress, performance, and conformity with program requirements
- Assist in managing outpatient referrals for PRC
- Follow up outside inpatient referrals for continued follow up, I.E., appointments and PHN referrals
- Will provide coverage for the inpatient units-ACU, PEDS, ICU, OB, and ER to include Outpatient Clinics Manages care of prioritized TCRHCC/SPHC outpatient/inpatient based upon consultation from providers within the TCRHCC/SPHC healthcare delivery system; provides a consistent and on-going consultation with service providers.
- Works proactively and collaboratively with Utilization Review (UR), Public Health Nursing (PHN), Patient Benefit Coordinators (PBC), and Purchased Referred Care (PRC) at TCRHCC/SPHC.
- Facilitates communication and coordination between members of the health care team, involving the client in the decision-making process in order to minimize fragmentation in the services (CMSA, 2010).
- Develops with the patient/family and multidisciplinary team (including service area and/or other non-TCRHCC/SPHC providers as appropriate) a care and service delivery plan based upon the needs identified and available provider and financial resources of the patient and provides consistent and on-going case consultation with all direct service providers.
- Provides service monitors and follow up to ensure continuity of care, and updates of the client service plan and provides follow up if needed. Striving to promote client self-advocacy and self-determination (CMSA, 2010).
- Prepares patient and family for termination (discharge) from case management when services are no longer required. Arranges for any ongoing support/direct care services that the patient will need post-discharge in coordination with discharge planners and other entities such as PHN, Community Health Representatives or Tribal Social Services.
- Will be familiar with Advance Directives, and be a resource person for patients and families; facilitate informed choice, consent, and decision-making.
- Promote use of evidence-based care, as available, in conjunction with the MCG Care Guidelines.
- Pursue professional excellence and maintain competence in practice.
- Serves as the outpatient/inpatient coordinator, such as:
- The primary contact for outpatient/inpatient in obtaining beds for admissions both within and outside of TCRHCC/SPHC.
- Collaborates with provider and nursing personnel to ensure admissions are conducted seamlessly and without delay of patient care.
- Collaborates with provider, nursing personnel and patient benefits coordinators that all admission documentation is complete and all referrals for third party resources are complete prior to the departure of patients.
- Will share in coverage all units, inpatient and outpatient for staffing shortages.
- Incumbent will be required to take call on scheduled weekends as deemed necessary
- Responsible for electronic health records data entry pertinent to patient service role
- Performs other duties as assigned.
Considerable judgment is essential in interpreting and applying program guidelines to ensure timely assistance with patients assessed needs. Additional guidance is provided on controversial matters when problems are encountered regarding this approach to outpatient management. Incumbent will perform within established objectives/ parameters and independently work out and revise methods, processes and procedures with professional and other staff. Identifies and seeks innovative approaches to resolution of problems. Able to seek assistance and identify when limitations have been reached.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Work requires walking, periods of standing, and sitting. Work also requires extensive periods of time working at a personal computer. Must be able to lift up to 25 lbs (i.e. medical charts); must be able to distinguish numbers, letters, and colors.
Contacts often require tact and sensitivity as those related to stressful situations such as death, dying and catastrophic illnesses. Must be able to prioritize, use good judgment, and coordinate a variety of issues while being frequently interrupted.
The incumbent performs difficult and complex assignments that are Service Unit wide in scope and encompass a variety of compliance activities and requirements. The work requires the ability to deal relatively independently with the interrelated elements that affect patient services and assessed needs in order to resolve or prevent any delays in service and any other controversial matters that may arise. The work requires diversity in professional nursing/ social work and compliance knowledge and experience.
The Case Manager directly affects the proper function and quality of healthcare provided within TCRHCC/SPHC. Case Managers emerge as an important intervention that fosters the careful shepherding of health care dollars while maintaining a primary and consistent focus on quality of care and client self-determination (2010, CMSA).
TCRHCC is located within the Navajo Nation and, in accordance with Navajo Nation law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this Policy, applicants who are enrolled members of the Navajo Nation and who meet the necessary qualifications for this position will be given preference in hiring and employment for this position and applicants who are enrolled members of any other tribe who meet the necessary qualifications will be given secondary preference.
In performance of their respective tasks and duties, all employees at TCRHCC are expected to conform to the following:
- Adhere to all professional and ethical behavior standards of the healthcare industry.
- Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
- Possess cultural awareness and sensitivity.
All employees must uphold all principles of confidentiality and patient care to the fullest extent. This position has access to sensitive information and a breach of these principles may be grounds for immediate termination.
I have read the qualifications and requirements for the position of Social Worker Case Manager. To the best of my knowledge, I believe I can perform these duties.