US:

NV:

Carson City Case Management Per Diem 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 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) Performs other related duties as assigned.