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US:NV:Carson City Case Management


Full Time Day Shift

Summary


  • 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.
  • The overall responsibility to assess the patient for transition of care needs and risk for readmission.
  • This individual will be able to conduct complex psycho-social assessments and provide interventions to assist with throughput, safe discharges and avoid readmissions.
  • Has focus on complex social and post-acute care services.

Qualifications

Required:

  • Master in Social Work from accredited school of Social Work
  • Excellent interpersonal, written and verbal communication skills
  • Demonstrated organizational skills, critical thinking and problem-solving skills and computer literacy
  • Unrestricted licensure in the State of Nevada in one of the following:
    • Licensed Social Worker (LSW)
    • Licensed Masters Social Worker (LMSW)
    • Licensed Clinical Social Worker (LCSW)

Preferred:

  • Two (2) years of acute care coordination experience
  • Ability to obtain Accredited Case Manager (ACM) certification

Unit Specific Requirements

Behavioral Health Services

Required:

  • Non-Violent Crisis Intervention (NVCI)
    • If hired prior to 8/6/2023, must successfully complete NVCI by June 30, 2024.
    • If hired after 8/6/2023, must successfully complete NVCI within six (6) months of hire or position entry.
  • Current, unrestricted driver's license

Essential Functions


Transition Management

  • Completes initial /comprehensive assessment within 24 hours of admission, including anticipated transition (discharge) plan.
  • 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.
  • Ensures plan of care and interventions are implemented and communicated to health care team, patient/family and post-acute care providers.
  • 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.
  • Assists with adoption/abuse/neglect cases and reports to appropriate external agencies as required.
  • 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.
  • Provides education to medical and nursing staff regarding relevant issues related to transition plan.
  • Precepts new staff members and acts as resource to all staff.

Compliance

  • Ensures compliance with local, state and federal regulations and accreditation requirements.
  • Operates within social work scope of practice as defined by the state licensing board.
  • 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).
  • Escalates barriers to transition planning per departmental escalation plan.
  • Completes post-acute referrals within 3 days of admission.
  • Schedules and facilitates complex case patient/family conferences as needed (at a minimum of weekly).

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