Care Manager - Social Worker
Core
Assess psychosocial needs and develop continuing care plans to ensure effective patient care after hospital discharge.
Role type
Hospital social worker (discharge planning)
Builds
Continuing care plans and discharge coordination
Domain
Healthcare / Social Work
Deliverable
client delivery
Required skills
Psychosocial assessment, care plan development, counseling, motivational interviewing, community resource navigation, advance directives education, end-of-life care discussion, cultural competency, multidisciplinary team collaboration
Preferred skills
Experience with difficult or noncompliant patients, substance abuse counseling, process improvement initiatives
Technologies
Electronic medical record systems
Responsibilities
Interview patients and family members to identify needs; facilitate family meetings; coordinate complex care plans involving home health, social services, rehabilitation, and mental health providers; advocate for patients to receive needed resources; educate patients on health insurance and rights; participate in department initiatives for process improvement.
Seniority
Mid-level, hands-on IC