Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Coordination of Care

Job Family

Professional

Work Shift

Days (United States of America)

Summary

Comprehensively plans for services for a targeted population. Responsible for psychosocial assessments, crisis intervention, discharge planning, and coordination of referrals and resource information to patients and families in need of assistance. Independently identifies complex patients as well as receives referrals from nursing and other ancillary staff. Provides an array of social work services to patients and families to promote understanding and resolution of problems related to environmental stress, physical illness, interpersonal conflicts, and other psychosocial issues. Adheres to the patient experience initiatives and champions customer service. Works collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum at the appropriate level of care.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Conducts face-to-face interviews with patients and family members to develop therapeutic relationships and obtain psychosocial and financial information necessary for the facilitation of appropriate discharge planning

• Performs proactive screenings and assessments for patients’ clinical, psychosocial, and discharge planning needs

• Documents assessment, the on-going plan, case progress, intervention(s), and reassesses patients as needed

• Initiates referrals and recommends consults to enable patient to be prepared for safe and timely discharge or transfer

• Assists patient/family in coping with hospitalization, disability, and chronic/terminal illness

• Utilizes communication, negotiation, and advocacy skills with patient, family, healthcare team and community

• Provides information, education to patient/family on community resources and options for post-acute care appropriate to the age of the patient served

• Carries out discharge planning activities to include providing arrangements for Home Health, Hospice, Home Infusion, DME, Outpatient Hemodialysis, Rehab, LTAC, Assisted Living, Rest Home and Skilled Nursing Facility placements

• Provides alternate plan of care options at the appropriate level of care based on patient/family needs and in collaboration with physician and/or designated team members

• Serves as a resource for processing issues such as guardianship, abuse, neglect, power of attorney, healthcare surrogate, advance directives or psychiatric involuntary commitment.  Initiates/completes forms required for post-acute placement.

• Serves as a reliable resource for the Acute Care Nurse Navigator for difficult placements, information on Medicaid and disability, and Department of Social Service Referrals

• Consults with the Acute Care Nurse Navigator when clinical explanation of disease processes, clarification of physicians’ orders, and other pertinent information is needed to determine, safe appropriate discharge plan

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Bachelor’s degree in Social Work required

• Master’s degree in Social Work (MSW) preferred

• Professional Certification in Case Management or Social Work (CSW, CCM, or ACM) preferred

Work Experience: 

• 3 years’ experience in Social Services, Home Health, Hospice or Acute Care setting required

• Acute Care Case Management experience preferred

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language

• Flexible with scheduled hours to meet the needs of the department, unit, patient and family

• Work is not standardized and requires a high degree of prioritization skills

• Excellent interpersonal communication and negotiation skills

• Ability to communicate effectively and work with people of all social, economic and cultural background

• Proven written, telephonic and electronic communication skills

• Assertive and persuasive in interactions with customers, peers, management and core staff served

• Strong organizational and time management skills

• Proficiency with various computer programs including Microsoft Office, Midas, ProviderLink, ValleyLink, eHIM, and SMS

• Ability to demonstrate respect and team building

• Flexible, open-minded and adaptable to change

• Ability to work collaboratively with department staff, physicians and healthcare professionals at all levels to achieve established goals, improve quality of outcomes, maintain or exceed Joint Commission standards and State mandates as they apply to the department operations

Physical Requirements: 

• Light carrying and lifting may be required

• Walking may be required to access all areas of the Medical Center

• Ability to effectively communicate orally to patients, family members, personnel and physicians

• Visual acuity to proofread hand or typewritten materials

• Manual ability to use telephones and computer keyboard

Required Licenses and Certifications

CSW - NC Social Work Certification And Licensure Board

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity