Social Work Care Manager

McLaren Health Care - Pontiac, MI

Full-time - Mid Level

Pontiac, MI

Nursing and Residential Care Facilities

About the position

The Social Work Care Manager plays a crucial role in providing assessment and intervention services to clients and families facing social and economic challenges that impact their health and wellness. This position focuses on professional discharge planning, ensuring that patients receive the necessary resources and support for a successful transition from hospital to home or other care settings. The role involves collaboration with interdisciplinary teams to address complex psychosocial issues and facilitate access to community resources.

Responsibilities

• Performs high level triage of all patients, focusing on identifying those with complex psych-social or financial issues within 24 hours of admission.
• Receives RN Care Manager referrals to social work based on identified Social Work Triggers.
• Identifies and assesses barriers early in the patient's stay, formulating a plan with the patient, family, and healthcare team.
• Assesses patient and family needs for support and community service needs, educating and referring them to resources.
• Assesses risk of readmission for specified patient populations and initiates interventions to enhance successful transitions.
• Identifies the need for, arranges, and participates in family care conferences and interdisciplinary conferences.
• Identifies and reports avoidable day/variances and/or service delays from the established plan of care to leadership.
• Identifies patient and family preferences, needs, and strengths for the interdisciplinary team.
• Interviews patient and significant others to assess the patient's psychosocial situation.
• Develops discharge plans in consultation with the patient, family, physician, and healthcare team.
• Manages complex cases and advocates for patients and families during care planning.
• Uses knowledge of insurance benefits to maximize resource utilization.
• Documents assessments, plans, interventions, and barriers in the EMR to facilitate discharge.
• Works collaboratively with the RN Care Manager and other disciplines for safe transitions to the next level of care.
• Partners with external agencies to provide continuity of care for patient empowerment.
• Represents the integrated care management department on various teams and committees.
• Performs other related duties as required.

Requirements

• Licensed Master's Social Worker (LMSW); LMSW certification within one year of eligibility and maintenance of continuing education requirements.
• American Case Management Certification (ACM) or obtain certification when eligible.

Nice-to-haves

• Certification in Case Management Certification (ACM or CCM)
• Three years acute hospital care or social work experience
• Basic Life Support (BLS) certification as a Healthcare Provider.

Benefits

• Health insurance coverage
• Paid holidays
• Flexible scheduling
• Professional development opportunities