Social Worker Case Manager

• Participates in the assessment of patients' biopsychosocial needs through review of patient 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 the 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 have been communicated to patients/families and members of the healthcare team and are documented as necessary to ensure continuity of care. Refers cases and issues appropriately to resolve barriers to care progression. Acts as an advocate for patients to resolve barriers to care progression.
• On the basis of preliminary risk screenings, assesses the psychosocial risk factors of patients/families through the evaluation of prior functional levels, appropriateness/adequacy of support systems, reactions to illnesses and the ability to cope.
• Intervenes with patients/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 patient/family empowerment and independence to make autonomous healthcare decisions and access needed healthcare services.
• Provides discharge planning and continuity of care for assigned patients in the acute and post-acute settings
• Initiates and 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, delivery of post-discharge services and transition of patients from the hospital to the discharge setting as well as ongoing care in the community.

• Education: Master's Degree in Social Work (MSW)
• Experience : Requires a minimum of 1 year of experience in clinical care or clinical case management.
• Certification: Basic Life Support (BLS) for Healthcare Provider certification from the American Heart Association required upon start.

Inova Health System is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, pregnancy (including childbirth, pregnancy-related conditions and lactation), race, religion, sex, sexual orientation, veteran status, genetic information, or any other characteristics protected by law.We are Inova, Northern Virginia and the Washington, DC, metropolitan area’s leading nonprofit healthcare provider. With expertise and compassion, we partner with our patients to help them stay healthy. We treat illness, heal injury and look at a patient’s whole health to help them flourish. Through our expansive network of hospitals, primary and specialty care practices, emergency and urgent care centers, and outpatient services, Inova provides care for more than 1 million unique patients every year. Total patient visits exceed 4 million annually, demonstrating our ability to deliver the best clinical care and ensuring a seamless experience for all who rely on us for their healthcare needs. Consistently ranked and recognized as ... a national healthcare leader in safety, quality and patient experience, Inova’s world-class care is made possible by the strength and breadth of our network, our 24,000 team members, our technology and our innovation. Inova is home to Northern Virginia’s only Level 1 Trauma Center and Level 4 Neonatal Intensive Care Unit and provides high-quality healthcare to every person in every community we are privileged to serve – regardless of ability to pay – every day of their life. More information about Inova can be found at Inova.org.

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