The Medical Social Worker Care Manager is a key associate at Hope Network whose primary responsibilities include: Facilitates the care plan for the treatment episode, proactively monitors clinical quality, facilitating timely discharge planning while also serving as social worker to consumers and families. Coordinates the efforts of psychiatry, physiatry, psychology, nursing, PT, OT, SLP, therapeutic recreation, throughout the episode while integrating the family in the plan. This role facilitates real time communication from the treatment team to the external Nurse Case Manager, insurance adjustor, and external physicians serving the patient. They serve as an advocate and liaison for and on behalf of consumers' rights and benefits. They evaluate, facilitate and monitor services and client progress in relationship to established goals and objectives.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
This is not intended to be an exhaustive listing of job functions. This job description is in no way states or implies that these are the only duties to be performed by this employee. The employee is required to follow any other instructions and to perform any other duties as assigned.
1. Regular and predictable attendance is an essential requirement of this position.
2. Responsible for a smooth intake process for each new consumer assigned to their case load including:
• Ensure consumers are assigned a complete treatment team as determined by their needs and physician orders and that their schedule is complete;
• Address any admission day medical, personal care, and rehabilitation needs;
• Verify that all priority evaluations are completed and findings are implemented to ensure a safe and comfortable transition for the consumer;
• Complete all required intake documentation;
• Obtain copies of all necessary documents for invoicing of services including identification, insurance plan, insurance cards and legal forms if not yet received.
3. Responsible to oversee the medical care of the consumer by:
• Working cooperatively with nursing and direct care staff; and
• Ensuring medical follow-up and care is provided including, but not limited to, scheduling and coordinating medical appointments and transportation, securing medical orders and treatment prescriptions at required intervals, and attending medical appointments when appropriate.
4. Serves as the primary point of contact for outside parties such as physicians, rehabilitation nurses, adjustors, families/guardians, and other service providers. Keep all external parties informed, at their desired level and frequency, of the progress being made in the program. Portrays a positive, professional image of the program.
5. Coordinate with the treatment team to ensure that consumer programs are coordinated and outcome oriented showing movement through the continuum of care, as appropriate. Facilitate treatment plan review with the team if progress slows or goals are not being achieved. Proactively escalates the case for review by a program manager/director when the case presents some challenge to achieving successful outcomes.
6. Makes internal referrals that allow HNNR new opportunities to serve a consumer who has either made progress and can benefit from additional services, or has developed previously unseen concerns that could be addressed by a referral to the appropriate professional.
7. Leads the treatment team in a manner that is conducive to problem solving and cooperation. Works with the team to develop a treatment plan that is functional, measurable and goal directed. Provides feedback to the team when progress is hindered or below expectations, before meeting with external stakeholders.
8. Ensures that extraneous information needed for decision-making, planning and execution of plans is provided and available to all team members. Able to generally represent the treatment plan and current issues during team meetings that either support the need for ongoing care or indicate discharge to less intensive services.
9. Oversees the consumer’s medical chart to ensure that information is updated in a timely fashion, physician scripts for services are current, and written documentation conforms to our licensing and accrediting requirements. Utilizes tools and alerts within the EMR to facilitate team communication.
10. Prepares reports that summarize the consumer’s treatment and plan as provided by the entire treatment team, to present to funders for approval of services. These reports include Team Treatment Plans, Periodic Reviews and Discharge Summaries. Follow prescribed formats and program requirements. Prepare special letters as needed including letters of Medical Necessity.
11. Understands the common funding sources for our level of care including auto no-fault, commercial health, Medicaid MOU program, and worker’s compensation. Understands and can explain patient responsibilities based on funding mix and coverage, including family responsibility of copayments and deductibles. Works with families to address collection issues. Reviews financial reports by case load as provided by the Finance Department.
12. Works with Funding Specialist to determine funding parameters, and communicates the limitations to all involved parties. Monitors team adherence to prescribed parameters. This includes monitoring of services for those consumers admitted under per diem agreements to ensure appropriate service provision is maintained. Researches unusual or limited funding situations and modifies program recommendations to best fit the availability of funding and desire of the financial guarantor while meeting the intended program outcome goal.
13. Ensures that a discharge plan is in place and community resources are explored and secured as needed. Provides options for consumers and family and works with them to make informed decisions.
14. Serve as a member of the inter-disciplinary team to provide pertinent psychosocial information and an assessment of the family’s ability to understand and cope with the consumer’s challenges. Provide assurance to family that the team is working toward the consumer’s goals.
15. Serves as a primary therapist as assigned to provide and/or coordinate psychosocial services to individuals. These services may include, but are not limited to:
• Individual counseling supporting adjustment issues and other appropriate concerns
• Substance Abuse intervention and education
• Psychoeducation, community resource information and referral, as needed
• Referral to specialized treatment, such as substance abuse counseling, spirituality counseling, etc.
• Crisis management
• Psychosocial consultation to other staff members to help address individual behavioral and communication needs
17. Serves as a primary family contact person. These services may include, but are not limited to:
• Individual/group/family counseling
• Dissemination of essential information regarding family and/or family dynamics
• Parenting skills training
• Family advocacy
• Crisis intervention
• Substance abuse intervention and education
• Referral to community support resources
• Assistance with discharge planning
• Assist families/guardian/caseworker with SSDE/Medicaid applications/medical benefits
• Assist families with housing opportunities
18. Supervises, trains, and evaluates Social Work students, after 1 year of employment.
19. Primary contact for coordination and delivery of consumer and family education and training.
Ensures that all necessary education occurs and is satisfactory for a safe and optimal discharge to the
next setting of care.
20. Provides a quality review of consumer schedules and program participation. Ensures that all
consumers on caseload are receiving the prescribed therapies and medical services at appropriate
frequencies. Works with scheduling to resolve any issues of reduced treatment.
21. Is responsible for the timely, accurate and complete collection of outcome data for their caseload as
identified by program administration.
22. Provides organized and effective communication to internal and external sources both in written and
23. Works cooperatively with program administration to address quality concerns stated by consumers,
families, and outside professionals.
24. Serves as on-call emergency contact for both residential and community individuals on a rotating basis.
Educational / Talent Requirements:
1. Minimum education required: Master’s Degree in Social Work (M.S.W.). Two years of case management experience preferred or related social work experience.
2. LLMSW working towards full license.
3. Demonstrated verbal/written communication skills.
4. Demonstrated ability to work effectively with all levels of staff. Sensitivity to complex organizational and interpersonal dynamics.
5. Ability to interface effectively with professionals from outside agencies.
6. Ability to articulate and actively support the mission of the corporation to various audiences.
7. Excellent organizational and problem solving skills.
8. Valid driver’s license and driving record acceptable according to HN policy.
9. Ability to work with little supervision or direction.
Work Experience Requirements:
1. At least two years of experience in a health/human service field with an emphasis in rehabilitation.
2. Experience coordinating care and facilitating communication between caregivers and families.
3. Demonstrated ability in creating accurate and detailed notes/records.
4. Demonstrated ability in leading a team and providing direction.
5. Demonstrated problem solving skills.