Employment Type:Part timeShift:Day ShiftDescription:Job Summary:Responds to referrals by assessing and providing resources to patients at high risk for complex psychosocial needs. Identifies appropriate financial and community resources to meet the patient needs in collaboration with the Clinical Care Coordinator. Obtains and coordinates existing resources to meet the patient needs, not available via usual services. Serves as a liaison between patient/family and agencies/community services. Such patients may include but not limited to the following which require appropriate intervention and discharge planning.Completes psychosocial assessment, as the need is determined by the Clinical Care Coordinator clinical assessment.Participates in intra departmental service teams, task forces, committees, and Performance Improvement teams.Identifies situations requiring Manager or Director intervention.Addresses advance directives and end of life issues and facilities completion of appropriate documentation relates to patient decisions.Job Requirements:Must have MSW, previous case management experience and hospital experience preferred. Must have computer skills and ECIN software skills preferred.Responds to referrals by assessing and providing resources to patients at high riskfor complex psychosocial needs. Identifies appropriate financial and communityresources to meet the patient needs in collaboration with the RN Case Manager.Obtains and coordinates existing resources to meet the patient needs, not availablevia usual services. Serves as a liaison between patient/family and agencies/communityservices. Such patients may include but not limited to the following which requireappropriate intervention and discharge planning:
Physical/Substance Abuse.
Domestic Violence
Financial Issues (Social Security/Disability Issues)
Admission to Nursing/Retirement Facility
Linkage to legal services
Support group referral/facilitation
Adoption
Adult/Child Protection
Tutoring
Dysfunctional Family Systems
Baker Act Placements
Guardianship referrals
Hospice referrals
Indigent patient referrals
VA Hospital Referrals and transfers
SNF/ALF- referrals and transfers
Home Healthcare
Completes psychosocial assessment, as the need is determined by the Nurse CaseManager clinical assessment.
Provides counseling, emotional support, and education regarding adjustment ti illness.
Prepares the family for the reality of caring for the patient on an on-going basis.
Advocates for the patient's rights and entitlement.
Participates in team/family conferences giving necessary emotional and social information
to the team. Requests ethics consultation, as required.Participates in intra departmental service teams, task forces, committees, andPerformance Improvement teams.Identifies situations requiring Manager or Director intervention.Addresses advance directives and end of life issues and facilities completion ofappropriate documentation relates to patient decisions.Maintains competency and participates in continuing education workshops and seminarspertinent to new regulations, resources and process improvement.Provides on-call services after regular business hours of the Department in order toassure coverage of any patient emergencies including abuse.Demonstrate the application of ECIN utilization for discharge planning and referrals.
Documents 100% of discharge planning and patient referrals utilizing ECIN software.
Generate a discharge packet for each patient/family providing information for the
discharge plan.
Close referrals consistently.
Print 100% of clinical documentation and place in patient's medical record under the Case
Management tab.Demonstrates the application of Canopy Software utilization.
Print 100% of clinical documentation and place in patient's medical record.
Minimum Qualifications
Bachelors Degree is required; Graduate of an accredited school of Social Work with a
Masters Degree is highly preferred.
Minimum of two (2) years clinical experience in an acute care hospital or community
service setting is necessary.
Leadership, communication, and teaching abilities are necessary
Our Commitment to Diversity and InclusionTrinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.Our Commitment to Diversity and InclusionTrinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.EOE including disability/veteran