MINIMUM QUALIFICATIONS:

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certification in Case Management.
EXPERIENCE:
1. Two (2) years' social work experience. 

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Complete a comprehensive assessment to develop a safe, realistic discharge plan of care appropriate for the patient, in consideration of psychosocial, emotional and financial needs, and in collaboration with the care management team and documents in the electronic medical record.
2. Assess changes in the physician’s plan of care and any impact on the discharge plan.
3. Reviews discharge plan on an ongoing basis and communicates any changes to the appropriate party. Documents the discharge plan in the electronic medical record.
4. Identifies potential problems with post-discharge care and /or initiates early referrals to promote proper utilization of hospital resources and timely transfer to the appropriate level of car.
5. Assists the interdisciplinary team in identifying alternate methods and level of care when patient does not require acute hospitalization and takes appropriate action to minimize financial loss to the hospital and improve the quality of patient care delivery (discuss cases with patients and families, consult with physician).
6. Explore and collaborate with resources within the hospital and community to meet defined patient needs and refers patients and/or families to resources including but not limited to income assistance programs, transportation services, meal assistance, etc.
7. Assess for signs and symptoms of abuse and/or neglect and make referrals to appropriate agencies (Adult Protective Services or Child Protective Services).
8. Assist in identifying a decision maker of medical (Health Care Surrogate) or if there is an existing Medical Power of Attorney designee and presence of a Living Will or other advance directive. Assist patient in completing Living Will, Advance Directive and Medical Power of Attorney (MPOA) forms as requested.
9. Work with hospital legal counsel in pursuing and expediting guardianship, and/or conservatorship actions when necessary.
10. Provides education and guidance to physicians, patient, family and other health care professionals about Medicare, Medicaid and other third party payers coverage issues and regulations.
11. Communicates to case management leadership or designees and/or appropriate physician, medical staff director/peer review regarding deviations from expected norm, quality or appropriateness of care; length of stay issues; risk management issues.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Prolonged periods of standing or sitting. 

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Flexible hours to include weekends and holidays.

SKILLS AND ABILITIES: