PeaceHealth is seeking a Care Management/Medical Social Work - Anticoagulation & Diabetic Education for a Full Time, 1.00 FTE, Day position. Hourly compensation starts at $31.18, more depending on experience.
Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.
Responsible for identifying and interacting with medically and psychosocially complex patients and families who are likely to benefit from care management and meet high risk criteria and for coordination of discharge planning services for these patients in collaboration with RN Care Management and other members of the care team.
Details of the position
- Screen and identify patients who need care management per high risk criteria.
- Assess, develop, implement, and monitor a comprehensive discharge plan of care through an interdisciplinary team process in conjunction with the patient and family. Collaborate with the multi-disciplinary team to identify problems or needs that require special planning, intervention, teaching or follow-up.
- Identify key problems, strengths, and resources to be addressed in the discharge plan of care. Coordinate and facilitate improved ability to comply with plan of treatment; counseling or support needed to cope with situation; improved ability to access appropriate level of care due to lack of financial resources or lack of available service.
- Actively support measures that promote effective use of resources.
- Identify, plan, and arrange for appropriate services applying a knowledge of services available in the community, state, and federal health regulations and admission, discharge, and appropriate level of care. Coordinate effective planning and arranging for needed services upon discharge.
- Intervene by arranging services, education and providing psychosocial support to prepare the patient and their family to manage their healthcare needs within the acute care setting and post discharge.
- Coordinate with the interdisciplinary team and community resources when appropriate, regarding the multiple details of transitional care management plan. Consult with physician as indicated.
- Works with patients identified and referred to them by RN Care Management and/or other members of the care team, as well as by patients/families.
- Conducts evaluation to include appropriate documentation and the effectiveness of the Care Management services. Collaborates with team members to identify cause and adjust plan if patient’s health status is not improving.
- May counsel patients and/or families to facilitate and/or participate in community care services, in coordination with the physician and treatment team. Works as an integral member of the treatment team in the coordination of treatment and transition of care planning. Assesses and addresses both mental health and chemical dependency conditions. May perform risk assessments for suicidality and homicidally.
- Performs other duties as assigned.
What you bring
- Master’s degree in social work (MSW).
- In lieu of an MSW, the following qualifications and experience may be accepted:
- Master’s degree in counseling or related field with a minimum of two years’ work experience in a medical or healthcare setting, social service agency, or community organization focusing on health and/or welfare issues.
- Bachelor’s degree in social work or related field with a minimum of four years’ work experience in a medical or healthcare setting, social service agency, or community organization focusing on health and/or welfare issues.
- LCSW with substance abuse experience / CADC preferred.
- Must qualify for Medicare provider number which allows for billing counseling services.
- Minimum of two years employment in a healthcare setting or community agency dealing with health and/or welfare issues preferred.
PHMG PHYSICAL AND CONGNITIVE REQUIREMENTS
- Work requires normal amounts of physical effort at least 66% of the time.
- Ability to lift objects weighing 30 lbs. or less.
- Work is performed under normal working conditions with adequate lighting and ventilation.
- Job duties frequently require intense concentration and attention to detail (34-65% of work time).
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For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.