POSITION SUMMARY
Incumbent serves as an Outpatient/Inpatient Social Worker/Registered Nurse (RN) 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/RN 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/RN Case Manager is responsible for assessment, service planning, and resource acquisition, monitoring progress and initiating and responding to emerging client needs. The Social Worker/RN 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/RN 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/RN Case Manager will work with a multidisciplinary team within the service delivery setting. The Social Worker/RN 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/RN Case Manager will be responsible to the Director of Case Care Coordination.
ESSENTIAL FUNCTIONS
- 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
- Ensure proper PPE is worn at all times while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
- Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updated)
- Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction
- Performs other duties as assigned.
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.
Physical:
This position requires an individual of high energy who can maintain a long and flexible schedule to meet the management requirements. The physical requirements include; sitting at a desk for long periods of time, long periods of sitting in meetings; frequent sitting for intense work on a personal computer, frequent walking to interact with staff within the facility, frequent bending, kneeling, crouching, twisting, maintaining balance and reaching.. Must be able to hear, speak and comprehend over the telephone and in person with others. Must have ability to lift, push and pull up to 50lbs frequently. Sensory requirements for position include prolonged ability for far, near, and color vision, depth perception, seeing fine details, hearing normal speech, telephone use and ability to frequently hear overhead pages. Must have ability of both hand manipulation in simple and firm grasping, fine manipulation, and use of keyboard.
Mental:
Uses independent judgment and analytical skills to make decisions that impact operations, finances, and customer service within the organization. The incumbent must have the ability to perform in structured and unstructured environments and possess a keen attention to detail and propose practices/mechanisms to enhance customer satisfaction. Must have ability to continually concentrate, handle a high degree of flexibility, handle multiple priorities in stressful situation, demonstrate high degree of patience, adapt to shift work, work in areas that are close in crowded, frequently cope with high levels of stress, make decisions under high pressure, work alone, and occasionally cope with anger/fear/hostility of others in a calm way and manage altercations.
Environmental:
May frequently be exposed to chemical agents, extremes in temperature of humidity, occasional exposure to infectious diseases, dust, fumes, gases, hazardous or moving equipment, and loud noises.
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