Social Worker Pulmonary Hypertension John C. Lincoln Clinic

JOB SUMMARY: Accountable for an assigned caseload, works collaboratively with patients, caregivers, healthcare providers, and external partners to ensure that care is coordinated and complex information is provided across the health care continuum, resulting in a smooth transition of care with positive patient/familyESSENTIAL FUNCTIONSCollaborates with patients/caregivers early in the inpatient, and/or outpatient episode in preparation for discharge to include supportive care, end-of-life decisions, community resources/programs, goal setting, and long-term planning needs. Interviews, identifies and executes safe post-acute interventions to include pre/post discharge home visits, behavioral health service coordination, guardianship, repatriation, adoptions, CPS, APS, ALTAC, etc. Assesses readmission risk and barriers to care outpatient including home support, medication management, expectation, etc. Initiates and assists patients with advance directives. Facilitates smooth and timely transition from acute care to the appropriate level of care by providing communication of clinical information and plan of care between the hospitalists, specialists and PCP, as well as other key providers. Communicates financial obligations and other key information pertinent to the discharge plan to the patient, family, MPOA, etc. Assures effective transition and final hand-off to the next appropriate level acuity case management team. Communicates key information regarding inpatient stay and discharge plans to payer in order to obtain authorization for services. Promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process. Participates in the development and maintenance of Case Management metrics. Maintains and manages to caseload. May act as a patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication and monitors patient care to ensure that the patient receives quality care through the use of standards of care and evidence based practice guidelines. Advocates utilizing knowledge of applicable laws, regulations, government and insurance benefits as well as practice guidelines and standards of practice. Performs other related duties as assigned or requested. EDUCATIONMasters in Social Work RequiredEXPERIENCE1 year as a Licensed Social Worker, and/or successful completion of health related field placement in Master's level Social Work Program. Required 2 years in case management Preferred 3 years as a Licensed Social Worker Preferred Other Experience in management of behavioral health patients PreferredLICENSE AND CERTIFICATIONSLicensed Social Worker (LSW) - License Required orLicensed Clinical Social Worker (LCSW) - License Required orLicensed Master Social Worker (LMSW) - License Required Certified Case Manager - Certification Preferred