Job Description

Job Summary:

Interviews and assesses each patient, family, or other designated person(s) within 48 hours of admission to obtain financial, emotional, physical, social, functional and health care needs to define and recommend potential discharge plans, manage patient and family expectations, identify readmission risk and target interventions to reduce risk for readmission, and identify, adjust and manage barriers to discharge.

Essential Duties:

-Demonstrates skill in communicating with physicians the necessary documentation required to demonstrate medical necessity.

-Elevates to Supervisor and/or Medical Director all patients not meeting criteria after discussion with physician.

-Demonstrates skill in educating patient, family and interdisciplinary team regarding post-acute care options, status determination, and other care coordination services.

-Develops implements, coordinates, monitors, and evaluates preliminary and final discharge plans with the interdisciplinary team, patient, and family.

-Arranges and/or facilitates identified discharge needs and services of patients and ensures timely intervention to prevent delays in service and transition of care.

-Ensures all elements of the plan of care have been communicated to the patient/family and members of the healthcare team to assure continuity of care.

-Participates and facilitates care progression in daily multidisciplinary rounds and addresses target length of stay with health care providers to achieve complete delivery of services within prescribed timeframe.

-Monitors length of stay and acts to mitigate overutilization and elevates to medical director as needed.

-Documents results of assessments, status assignment, and interventions and discharge planning in the medical record according to departmental policies and procedures.

-Response to Diversity: Uses holistic body, mind, spirit approach in provision of care by recognizing, appreciating, and incorporating cultural, spiritual, gender, race, ethnicity, lifestyle, socioeconomic, age, and value differences in practice.

-Provides Inpatient and Outpatient comprehensive clinical social work practice and case management to all special needs patients by providing non-discriminatory, comprehensive treatment and coordination of care to patients and their families from pre-admission to discharge and community follow-up.

-The social worker provides age specific psycho-social screening, psychiatric assessments, psychosocial assessment, clinical interventions, and treatments as well as discharge planning and utilization review to ensure appropriate benefits and best clinical and discharge outcomes. -Shifts may fluctuate to fulfill department staffing needs.

-On call, weekends, and holidays may be required.

-Travelers are first to float within facility and to alternate locations within 20 miles of permanent assigned location.

-Please note all travelers within CDS are required to float to all areas in which they are trained including ED and alternate holding areas to care for appropriate patients.

Skills:

Required Skills & Experience:

-Two (2) years’ current experience required in specialty.

-Must be a team player, flexible, and accustomed to fast paced environment.

-Must have successfully completed at least one thirteen (13)-week travel assignment.

Preferred Skills & Experience:

-N/A

Education:

Required Education:

-Associate's Degree in Nursing.

Required Certifications & Licensure:

-State of New Mexico or Compact State Nursing License.

-BLS certification required.

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