SLH Care Management Social Worker
Company: Alameda Health System
Location: San Leandro
Posted on: January 26, 2023
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Job Description:
Summary SUMMARY: -Restores patients to optimum health and social
adjustment, while facilitating a positive impact on the hospital
transition of care; informs the health care team of the patient's
social, emotional, environmental, and financial needs and resources
that may influence their treatment options and discharge plan;
assists case manager nurses with complex social situations and
discharge planning. DUTIES & ESSENTIAL JOB FUNCTIONS: - -NOTE: The
following are the duties performed by employees in this
classification. - However, employees may perform other related
duties at an equivalent level. - Not all duties listed are
necessarily performed by each individual in the classification.
1. Collaborates with Care Transition team and Health Advocates for
high risk patients for timely follow-up appointments and confirms
prior to discharge that complex patients are appropriately linked
to community services. 2. Coordinates patient care activities with
other members of the healthcare team, the patient, the patient's
representatives, and community partners and makes referrals as
appropriate. 3. Effectively intervenes in suspected abuse/neglect
cases and in complex or high risk situations as requested; is
competent to identify and intervene with high risk behaviors,
responding to traumas. 4. Identifies and mobilizes patients and
family strengths to optimize use of healthcare and community
resources; in coordination with patient and family wishes,
guide/assist in securing needed post discharge services which may
require negotiating for services covered but not readily available;
provides consultation and education to team members regarding
patient/family (psychosocial and discharge planning) issues and
community resources. 5. Identifies potential problems prevents and
or resolves variances to the care management plan; assesses and
coordinates family and community resources to meet identified needs
to support the discharge plan. 6. Intervene with patients and
patient's representatives regarding emotional, behavioral, and
financial barriers to current illness and/or disability. 7. Leads
patient centered conferences to meet needs and desires of the
patients. 8. Maintains patient records including patient
assessments, plans interventions, patient/family involvement,
outside agency communications and interdisciplinary contacts. 9.
Participates in discharge planning activities; effectively
identifies and intervenes with high risk discharge planning issues
with psychosocial complexity; whether referred by other healthcare
providers or identified through assessment. Assists Care Management
Nurse with discharge planning efforts as requested; obtains or
coordinates referrals for post-discharge service needs, if
required; mobilize resources to affect rapid and timely movement of
the patient through system to achieve targeted discharge times
established by AHS. 10. Performs psychosocial assessment interview
with patients and/or families and records this assessment in the
patient's medical record. Assesses patient's level of functioning,
environment, appropriateness and adequacy of support system related
to illness and ability to cope; reassesses the patient's condition
when changes occur and revises the care plan when appropriate.
Performs rapid assessments and developing crisis management plans
for referral, evaluation and admission. 11. Provides patient
advocacy including primary responsibility for initiating processes
regarding capacity determinations, grief counseling, and
conservatorship/guardianship; takes advocacy leadership role
regarding adoption/surrogacy cases. 12. Refers and assists
patients/families in applying for appropriate financial programs
(CCS, SDI, SSI, SSD, private pensions) and legal instruments as
needed. 13. Screen for any barriers to care such as substance
abuse, neglect, financial limitations or housing. 14. Serves a
resource and provides counseling and treatment related to
palliative care or end of life planning.
-MINIMUM QUALIFICATIONS: Required Education: Master's degree in
social work/welfare issued by a school accredited by the Counsel of
Social Work Education. -Preferred Education: Master's degree in
social work/welfare issued by a school accredited by the Counsel of
Social Work Education with Required Experience: Two years of Social
work or Case Management experience in an acute setting or
protective services. Preferred Licenses/Certifications: Active
certification in Case Management (ACM or CCMC), Current and valid
license as a Clinical Social Worker issued by the State of
California Board of Behavior Science Examiners. Bilingual
preferred. San Leandro Hospital
SLH Social Services
Full Time
Day
Care Management
FTE: 1
Keywords: Alameda Health System, San Leandro , SLH Care Management Social Worker, Healthcare , San Leandro, California
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