US:NV:Carson City Case Management
Full Time Day Shift
Summary
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This individual is responsible to facilitate care through the continuum utilizing effective resource coordination to promote optimal access to care balancing the patients’ resources and right to self-determination.
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The overall responsibility to assess the patient for transition of care needs and risk for readmission.
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This individual will be able to conduct complex psycho-social assessments and provide interventions to assist with throughput, safe discharges and avoid readmissions.
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Has focus on complex social and post-acute care services.
Qualifications
Required:
- Master in Social Work from accredited school of Social Work
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Excellent interpersonal, written and verbal communication skills
- Demonstrated organizational skills, critical thinking and problem-solving skills and computer literacy
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Unrestricted licensure in the State of Nevada in one of the following:
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Licensed Social Worker (LSW)
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Licensed Masters Social Worker (LMSW)
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Licensed Clinical Social Worker (LCSW)
Preferred:
- Two (2) years of acute care coordination experience
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Ability to obtain Accredited Case Manager (ACM) certification
Unit Specific Requirements
Behavioral Health Services
Required:
- Non-Violent Crisis Intervention (NVCI)
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If hired prior to 8/6/2023, must successfully complete NVCI by June 30, 2024.
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If hired after 8/6/2023, must successfully complete NVCI within six (6) months of hire or position entry.
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Current, unrestricted driver's license
Essential Functions
Transition Management
- Completes initial /comprehensive assessment within 24 hours of admission, including anticipated transition (discharge) plan.
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Provides psycho-social assessment and intervention for patients identified with behavioral health issues, lack of social support systems, financial barriers, end of life and plan of care adherence.
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Ensures plan of care and interventions are implemented and communicated to health care team, patient/family and post-acute care providers.
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Complete timely, accurate and concise documentation in the Electronic Medical Record.
Care Coordination
- Screens high risk and referred patients for psycho-social issues/barriers, that may impact the transition plan and intervenes as appropriate.
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Assists with adoption/abuse/neglect cases and reports to appropriate external agencies as required.
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Collaborates with patient/family/health care team to ensure patient preferences and choices are taken into consideration within the limitations of available resources.
Education
- Ensure patient/ family receive education appropriate to their specific discharge plan.
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Provides education to medical and nursing staff regarding relevant issues related to transition plan.
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Precepts new staff members and acts as resource to all staff.
Compliance
- Ensures compliance with local, state and federal regulations and accreditation requirements.
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Operates within social work scope of practice as defined by the state licensing board.
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Participates in department Quality improvement initiatives.
Complex Case Management
- Completes clear, concise and accurate initial/discharge planning/complex psycho-social assessments and reassessments per departmental guidelines (assessments within 24 hours of admission, reassessments every 3 days or as needed for change).
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Escalates barriers to transition planning per departmental escalation plan.
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Completes post-acute referrals within 3 days of admission.
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Schedules and facilitates complex case patient/family conferences as needed (at a minimum of weekly).