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8110 Gatehouse Road, Falls Church, VA 22042

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Social Worker Case Mgr II

Elderlink 622970 Full Time 12011 Government Center Parkway, Fairfax, VA, 22035, US

Job Description

As a Social Worker Case Manager ll, you will provide discharge planning and continuity of care for assigned patients in the acute and post-acute settings. To help achieve our mission, you will provide/evaluate biopsychosocial impact on patients' plans of care. Your ability to evaluate patients' abilities to progress throughout the continuum of care is of vital importance. Working collaboratively in communication with physicians, nursing and other members of the multidisciplinary care team to effect timely and appropriate patient management and the progression of care plans is essential. Your understanding of pre/post-acute resources is expected. Providing coordination of services while acting as a key Liaison between patients, families and the interdisciplinary healthcare team is essential. Showcasing a working knowledge of and experience in the utilization of management, managed care and payer issues is required.

Job Responsibilities
  • Initiates/facilitates referrals to clinics, home healthcare, hospice, SNF, acute rehab, LTAC, TCM, medical equipment and supplies as indicated.
  • Collaborates with the interdisciplinary care team, patients and families in the assessment/coordination of discharge planning needs, delivery of post-discharge planning needs/services, transition of patients from the hospital to the discharge setting as well as ongoing care in the community.
  • Documents relevant discharge planning information in medical records according to department standards and/or care management plans.
  • Collaborates/communicates with internal and external Case Managers.
  • Participates in the assessment of patients' biopsychosocial needs through review of information, personal contact with patients/families and interdisciplinary care team members.
  • Communicates routinely with patients, families, interdisciplinary care team members and other appropriate parties with regard to status of patients' care plans. 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 patients' care plans are documented properly and have been communicated to the patients/families and members of the healthcare team to ensure continuity of care.
  • Seeks consultation from appropriate disciplines and/or community services to assist with the facilitation of discharge and ongoing community care plans.
  • On the basis of preliminary risk screenings, assesses the psychosocial risk factors of patients/families through evaluation of prior functional levels, appropriateness/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 and end of life decisions.
  • Advocates for the empowerment and independence of patients/families to make autonomous healthcare decisions and access needed healthcare services.
  • Ensures safe care to patients by adhering to policies, procedures and standards within budgetary specifications including time/supply management, productivity and accuracy of practice.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competencies. Supports department based goals which contribute to the success of the organization.
  • Work holistically to ensure that care/discharge plans meet the physical, social and emotional needs of patients.
  • Acts as an advocate for patients to resolve barriers to care progression. Works with families exhibiting complex family dynamics that have a direct impact 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 patients' clinical presentation and education needs.
  • Receives referrals for complex patient problem resolution from care team members.
  • Validates discharge criteria for patients/families, alerts of newly identified resources and/or changes in previously identified resources in the community.
  • Refers cases/issues appropriately to resolve barriers to care progression.



  • MSW


  • 2 years of case management or clinical experience


  • ACM or CCM or CCTSW or N/ASW- CM (ASWCM) or LCSW
  • BLS through the American Heart Association