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8110 Gatehouse Road, Falls Church, VA 22042

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Social Worker Case Mgr II

Fairfax Medical Campus 609043 Full Time 3300 Gallows Road, Falls Church, VA, 22042, US

Job Description

A Social Worker Case Manager II provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting. Provides/Evaluates biopsychosocial impact on patient plan of care. Evaluates patient ability to progress throughout the continuum of care. Works collaboratively in communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely and appropriate patient management and the progression of the care plan. Psychosocial assessment and Interventions. Understands pre-acute and post-acute resources. Provides coordination of services and acts as key liaison between patient, the patient's family and the interdisciplinary healthcare members. Working knowledge /experience in utilization management, managed care and payer issues.

Job Responsibilities
  • Initiates and facilitates referrals to clinics, home health care, hospice, SNF, acute rehab, LTAC, TCM, medical equipment and supplies, as indicated.
  • Collaborates with interdisciplinary care team, patient and family in the assessment and coordination of discharge planning needs, delivery of post-discharge planning needs, delivery of post-discharge services and transition of the patient from the hospital to the discharge setting, as well as ongoing care in the community.
  • Documents relevant discharge planning information in the medical record according to department standards, and/or care management plan.
  • Collaborates/communicates with internal and external case managers.
  • Participates in the assessment of patient biopsychosocial needs through review of patient information, personal contact with patient/family, and interdisciplinary care team members.
  • Communicates routinely with the patient, family, interdisciplinary care team members and other appropriate parties with regard to status of patient care plan and progress toward treatment goals, identification of concerns and/or problems, problem-solving and assisting with conflict resolution when necessary.
  • Ensures that all options available to support a successful transition and elements critical to the patients care plans have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care. Seeks consultation from appropriate disciplines and/or community services to assist with the facilitation of discharge and the ongoing community care plan.
  • On the basis of preliminary risk screening, assess patient and family's psychosocial risk factors through evaluation of prior functional levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope. Intervenes with patients and families regarding emotional, social, and financial consequences of illness and or disability.
  • Serves as a resource person and provides counseling and interventions related to treatment decisions and end of life.
  • Advocates for patient and family empowerment and independence to make autonomous healthcare decisions and access needed services within healthcare.
  • Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
  • Work holistically to ensure that care plans and discharge plans meet the physical, social, and emotional needs of patients.
  • Acts as patient's advocate to resolve barriers to care progression. Deals with families exhibiting complex family dynamics that impact directly on patient care and discharge.
  • Understands utilization management and the use of clinical milestones to define transition timelines and community resources.
  • Understands post-acute care criteria and documents appropriate referrals based on patient's clinical presentation and education needs.
  • Receives referrals for complex patient problem resolution from care team members.
  • Validates discharge criteria for patient and families and alerts of newly identified resources and/or change in previously identified resources in community.
  • Refers cases and issues appropriately to resolve barriers to care progression.



  • 2 years of experience in clinical care or clinical case management.


  • Master's Degree in Social Work


  • BLS certified through the American Heart Association.
  • ACM or CCM or CCTSW.


  • Valid Virginia Licensed Clinical Social Worker.