Case Manager Outpatient - SW
Wellstar Health Systems

Facility: Kennestone Hospital
Job Summary: The Case Manager -Social Worker will: Work in conjunction with of a team of Nurse case managers, Social Workers, Registered Dietitians, Pharmacists, Physicians, Leadership of Population Health Management, and other members of the care team across the continuum of care. The Social Worker will have the opportunity to make a profound impact on the lives of people living with multiple chronic illnesses and complex social situations. Conduct comprehensive assessments, create plans of care, implement, monitor, and evaluate options and services required to meet an individual's complex health care related needs. This includes mental health and psychosocial needs to promote seamless transitions, quality, and cost-effective outcomes. Will coordinate services to set up any identified patient need. Will serve as a consultant to other RN Case Mangers and Care Team Members and make recommendations to assist with adequately meeting patient psychosocial/mental health needs. Will connect with patients in person, on the phone and through email, in the hospital, and in the physician's office - essentially however and wherever the patient needs assistance to improve their health, better understand their illness and coordinate their care. Will collect and track data and make recommendations for improvements with the team and across the system. Core Responsibilities and Essential Functions: ASSESSMENT * Conduct comprehensive assessment of patients needs, /gaps in care * Communicates and collaborates with multidisciplinary team on patients mental health and psycho/social needs. * Communicates effectively with patients and their families. * Proficient in negotiating complex systems to effect positive change. * Follow patients over time and continuously evaluate the plan of care for effectiveness. Adjust as appropriate. PLANNING * Consult with physicians, nurses and multidisciplinary professionals. Instructing other health care professionals as to the nature of the patients social or psychological challenges to help them in their treatments as well. * Knowledgeable regarding Medicaid/Medicare and other payer programs to guide patients and families. * Knowledgeable regarding recognizing and reporting abuse and neglect. Ability to guide the rest of the care team on completing these processes. * Provides guidance to members seeking alternative solutions to specific social, cultural or financial problems that impact their ability to manage their healthcare needs. * Keep detailed treatment records, data tracking and documentation. Evaluate for trends and make suggestions for improvement IMPLEMENTATION/EVALUATION * Demonstrates understanding of community resources and refers to agencies as appropriate to patient need. * Create a comprehensive inventory of local community and government resources for patients and their families. Facilitate the patients access to these resources. * Form relationships and works constructively with other community service professionals. * Makes referrals to and completes placement process to skilled nursing facilities, HH, DME, Hospice, drug and alcohol rehabilitation as appropriate. * Manages behavioral and psychosocial needs that result in improved clinical and financial outcomes and delivers social work interventions. * Facilitates and coordinates behavioral health resources as individual member needs are identified. * Acts as liaison and member advocate between the member/family, physician and facilities/agencies. * Evaluates members' ability to independently manage self and locate alternative resources when limitations are identified via standardized Social Work Psychosocial evaluation methods, processes and tools while maintaining accurate record of activities. * Other duties as assigned Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct. Required Minimum Education:

• Masters Social Work

Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated.

• Lic Clinical Social Worker GA or Lic Master Social Worker GA
• Basic Life Support or BLS - Instructor

Additional License(s) and Certification(s):Required Minimum Experience: Minimum 3 years experience as a social worker in an acute care setting or community-based organization. Required and Previous experience with managing a comprehensive case load and working as part of a client care team. Required and Knowledgeable regarding long-term care facilities, hospice, Georgia Medical Care Foundation, DFACS, SSA, managed care and insurance companies philosophies and principles along with various health delivery systems including acute, post-acute and community based. Required and Expertise in managing complex patient populations, transitions in care, placements, abuse and neglect reporting and community resources. Required and Excellent verbal and written communication skills. Required Required Minimum Skills: Computer Proficiency with MS office suite and working with excel spreadsheets. Skill in identifying problems and recommending solutions. Skill in preparing and maintaining records and written reports. Exceptional communication skills, both written and oral Ability to positively influence others with respect and compassion

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