Social Woker

Job Summary: Responsible for the functions of case management, utilization review, discharge planning and transition of care.
ESSENTIAL FUNCTIONS: Responsible for establishing and maintaining open, effective communication between the facility and alternate level health care organizations, patients and their families, physicians, and third party payers.
Acts as a patient advocate to hospital clients.
Determines medical necessity for admission and continued stay as well as patient status through appropriate application of nationally recognized criteria.
Provides clinically based case management, discharge planning and care coordination to facilitate the delivery of cost effective quality healthcare.
Provides patient/ family with information about home health care, skilled nursing facilities, rehabilitation facilities and appropriate providers.
Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered.
Maintains active communication with members of the multidisciplinary care team to affect timely and appropriate patient care and facilitate discharge.
The case manager/social worker is on site and available seven days a week, as well as holidays and therefore is required to work a weekend rotation an occasional holiday and required to be on-call.
ADDITIONAL RESPONSIBILITIES: As assigned.
MINIMUM POSITION EDUCATION/QUALIFICATIONS: Education –Graduate from an accredited school of Social Work preferred.
Or Bachelors degree in healthcare related field.
.
Work Experience - Five years clinical experience in an acute care setting is strongly preferred.
Training – Basic Computer License/Certification – Current New Mexico License as a Social Worker (LMSW) KNOWLEDGE/SKILL/ABILITIES: Maintains knowledge and understanding of Medicare and Medicaid guidelines and regulations pertaining to utilization review, discharge planning and Long Term Care (or transitional care).
Experience in the use of InterQual or Milliman criteria and review processes preferred.
Demonstrates the willingness to research, learn, and obtain knowledge for the performance of the position.
Knowledge in the areas of Case Management and Utilization Management, experience with managed care as it relates to third party payers preferred.
POSITION RESPONSIBILITIES: Directs, coordinates and provides Case Management to patients in caseload.
Assess patients to identify needs, issues, resource and care goals.
Completes Case Management assessment, reviews admitting diagnoses/problems, determines a plan to address patient’s needs and optional/preferred level of care.
Identifies potential transition planning problems in a timely manner to set up services required.
Works with the attending physician and care team members to move patient through the hospital system and set up appropriate services or referrals.
Works collaboratively to develop a discharge plan early in hospitalization.
Proactively affects the system to facilitate efficient flow of care.
Reviews patient admissions to determine the medical necessity for admission and continued stay using pre-established criteria.
Identifies cases that fail criteria and refers them to the physician advisor appropriately.
Assists and educates physicians on appropriate documentation warranting acute hospitalization.
Acts as a resource when issuing notices of non-coverage (Medicare HINNs), Condition Code 44, or the 2 Midnight Rule to both the physicians involved and the patients.
Explains UR processes and insurance coverage requirements.
Consults with physicians and their offices and payers, to determine the appropriate status of a patient.
Actively monitors observation status patients and seeks clarification of the status by the 24 hour mark and no later than 48 hours.
Provides clinical data/information to contracted third-party payers while the patient is hospitalized to ensure continued reimbursement and avoid delays in reimbursement with in the established timeframe set by the contracts.
Completes or oversees the completion of the Case Management Assessment of patients and support systems to facilitate the most appropriate and timely transition plan.
The completion of the Choice Form for Medicare.
Administering of the Important Message for Medicare.
The completion of assembling the necessary referral paperwork prior to discharge.
Documents offering of choice for SNF, DME or Hospice referrals according to Medicare requirements.
Communicates the discharge plan to patients/their representatives and pertinent healthcare team members.
Interacts, communicates and intervenes with the multidisciplinary healthcare team in a purposeful goal-directed fashion.
Works proactively to maximize the effectiveness of resource utilization.
Anticipates and facilitates problem resolution around issues of resource used and continued hospitalization and discharge planning.
Maintains a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
Utilizes appropriate resources in cases that present ethical dilemmas.
Explores strategies to reduce LOS and resource consumption.
Participates in daily rounds.
Refers to the PA those cases in which appropriate resource utilization is to be evaluated.
Reviews physician documentation and when needed seeks clarification relative to diagnosis and the patient’s clinical state.
AGE-RELATED COMPETENCIES: Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.
Knowledge of pediatrics to geriatrics is necessary.
Information Management: Treats all information and data within the scope of the position with appropriate confidentiality and security.
Risk Management/Quality Management/Safety: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.
ENVIROMENTAL CONDITIONS: Work environment consists of daily patient contact, which may include exposure to blood, or other body fluids.