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8110 Gatehouse Road, Falls Church, VA 22042

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Social Work Case Manager

Behavioral Health Services - Merrifield 609798 Full Time 8221 Willow Oaks Corporate Drive, Fairfax, VA, 22030, US
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Job Description

Job Responsibilities
 
  • 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.
    • 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.
  • Working knowledge /experience in utilization management, managed care and payer issues.
    • 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.
    • Refers cases and issues appropriately to resolve barriers to care progression.
  • Psychosocial assessment and Interventions.
    • 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.
  • Provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting.
    • 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.
  • 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.
    • 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.
Qualifications
Experience:  
•    1 year of experience in case management or clinical care.
Education:
•    Master’s Degree in Social Work.
Certification:
•    CPR certified through the American Heart Association.