**Our promise to you:**

Joining AdventHealth is about being part of something bigger. Its about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that **together** we are even better.

**Schedule:** PRN days; 8:30am-5pm; 6 shifts per 6-week schedule to include 4 weekday shifts and 2 weekends shifts and 1 summer holiday and 1 winter holiday

**Location:** UChicago Medicine AdventHealth Hinsdale Hospital, 120 N Oak Street, Hinsdale, IL 60521

**The role youll contribute:**

The Social Work Care Manager intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs, funding sources and qualify for community assistance from a variety of special assistance programs and agencies, and/or require assistance with transitions of care or discharge planning. In addition, offer crisis intervention to patients and families with psychosocial needs and coordinates and facilitates the development of a discharge plan of care for high-risk patient populations. This role will receive referrals for individuals from at-risk populations from interdisciplinary team members (including physicians, RN Care Managers, staff nurses, and other members of the care team). The Social Work Care Manager, in collaboration with the patient/family, care manager nurses, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination through the continuum of care. The Social Work Care Manager ensures efficient and cost-effective care through appropriate resources monitoring and clinical care escalations. The Social Worker is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The Social Work Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The Social Work Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and are core competencies of this role. The Social Work Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The Social Work Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The Social Work Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Social Work Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

**The value youll bring to the team:**

**** Psychosocial Assessment and Interventions

**o** Assesses patient's and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, assisting those coping with adjusting to significant life transitions

**o** Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs

**o** Serves as a resource to provide information and intervention related to treatment decisions, terminal illnesses and end-of-life issues

**o** Provides grief counseling and crisis intervention skills

**o** Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system

**o** Provides de-escalation services for patient/family as appropriate

**o** Provide Motivational Interview techniques for patients with substance use and addictive disorders

**o** Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention

**o** Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis

**o** Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers

**** Receives referrals for psychosocial complex needs from the health care team.

**** Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.

**** Provides consult services for patients who may possibly lack decision making capacity. Follows the guardianship (temporary/ permanent) policies and procedures and coordinates with Care Management leadership throughout the process.

**** Provides consult services for foster care and adoptions.

**** Assists the health care team in the patient assessments and placements for mental health services.

**** Facilitates full team discussion including patient and family when ethical dilemmas arise.

**** Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed

**** Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.

**** Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes.

**** Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.

**** Incorporate clinical, social and financial factors into the transition of care plan.

**** Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care.

**** Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient

**** Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.

**** Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans.

**** Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's readmission risk scores and coordinating readmission mitigation interventions.

**** Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.

**** Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.

**** Escalates issues barriers to appropriate level of Care Management leadership

**** Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.

**** Facilitates patient care conferences with multidisciplinary team as needed.

**** Establishes and documents, based on the predicted DRG and multidisciplinary team member's input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.

**** Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients

**** Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.

**** Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.

**** Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care

**** Ensures reassessment of discharge needs provided anytime a patient's condition changes and/or the circumstances impacting the provision of post-hospital care changes.

**** Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).

**** Communicate with patient/family the possible need to pay for services out of pocket.

**** Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for posthospital follow up care.

**** Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.

**** Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.

**** Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.

**** Participates in department and hospital Performance Improvement activities.

**** Provides necessary patient care coverage and assistance with other duties as assigned when needed.

**** 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.

**** Participates in facility and department regulatory and certification preparations.

**** Social Work Care Manager serves as a preceptor

**** Social Work Care Manager participates in department education (bulletin or presentation) with topic and content approved by Facility CM Director

Qualifications

**The expertise and experiences youll need to succeed:**

**KNOWLEDGE AND EXPERIENCE STRONGLY PREFERRED** :

Excellent interpersonal communication and negotiation skills

Critical thinking and problem-solving skills

Psychosocial assessment skills

Customer service skills

Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change

Effective organizational skills

Computer proficiency with Outlook e-mail and electronic medical records

Flexible in a complex and changing healthcare environment

Understanding of pre-acute and post-acute venues of care and post-acute community resources

Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources

Strong interview, assessment, and organizational skills

Leadership skills

Data analysis skills

**KNOWLEDGE AND EXPERIENCE PREFERRED:**

Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement

Knowledge of state and federal guidelines pertinent to Care Management

Ability to identify appropriate community resources and to work collaboratively with patients, families, multidisciplinary team and community agencies to achieve desired patient outcomes

**EDUCATION AND EXPERIENCE REQUIRED:**

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.