Provides patient and family advocacy, and support patients choice and patient rights during hospitalization. Communicates with Payors patients needs for authorization for post-acute care as needed. Documents discharge planning evaluation, ongoing assessment, discharge plans, MD - Rs, barriers to progression of care, avoidable days, and patient and family needs according to standard work. Other duties as assigned. Assesses patients and families wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning. Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan. Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs. Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate. Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate. Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services. Assesses readmitted patients for the patients and familys perceived reasons for the readmission. Organizes and facilitates patient and family care conferences with the multidisciplinary team. Knowledge, Skills, and Abilities: Excellent interpersonal communication and negotiation skills [Required] Critical thinking and problem-solving skills [Required] Customer service skills [Required] Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change [Required] Effective organizational skills [Required] Computer proficiency with Outlook e-mail and electronic medical records [Required] Flexible in a complex and changing healthcare environment [Required] Understanding of pre-acute and post-acute venues of care and post-acute community resources [Required] Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited or non-existent payment resources [Required] Psychosocial Assessment and Interventions [Required] Assesses patients and familys psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope [Required] Intervenes with patients and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs [Required] Serves as a resource to provide information and intervention related to treatment decisions and end-of-life issues [Required] Provides grief counseling and crisis intervention skills [Required] Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the healthcare system [Required] Provides de-escalation services for patients as appropriate [Required] Provide Motivational Interview techniques for patients with substance use and addictive disorders [Required] Provides patient/family education, adjustment-to-illness counseling, grief counseling and crisis intervention. Provides education to patients/families/caregivers regarding resource options and coping with diagnosis, treatment and prognosis [Required] Works in collaboration with hospital and community agencies to obtain needed services and resources for patients/families/caregivers [Required] Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement [Preferred] Knowledge of state and federal guidelines pertinent to Care Management [Preferred]Education: Bachelor's [Required] Master's [Preferred]Field of Study: in Social Work Required. Work Experience: 1 care management experience [Preferred] 1 years experience in social work [Required]Additional Information:Additonal Licensure or certification requirements may apply depending on the specific unit or state in which this position is located. Please consult the relevant credential grid for detailed information regarding these requirements. Licenses and Certifications: Accredited Case Manager (ACM) [Preferred] Certified Case Manager (CCM) [Preferred]Physical Requirements: (Please click the link below to view work requirements)Physical Requirements - 4 mja 2 Pay Range:$24.45 - $45.46