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Job ID: 59879
Location: Rocky Mount, NC
Facility/Division: Nash UNC Health Care
Status: Full Time
Shift: Day Job
Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.
The Social Worker facilitates effective and cost efficient care of patients through case management functions as discharge planning. May facilitate the execution of existing clinical pathways or may facilitate the implementation of new clinical pathways. May follow the patient through the continuum of care, or may concentrate on one aspect of case management, depending on the area assigned. In collaboration with the Interdisciplinary Patient Care Team, coordinates the implementation of the discharge plan when it calls for post-discharge home care or placement into nursing homes or rehabilitation facilities, or community services.
1. Identify Cases & Prioritize Day - Review and prioritize consults received. Participate in Daily Care Management Touchpoint per established protocols. If indicated, communicate with Care Management Assistant (CMA) to share priorities. In Communication And Patient Planning (CAPP) Meetings and Complex Care Meetings, identify patients who require a SW consult and collaborate with the CM regarding findings/needs
2. CAPP Meeting - Attend and actively participate in CAPP meetings for assigned units to provide and receive information on patients’ progression and psychosocial needs. Complete follow-up from CAPP as appropriate. For CAPP that the Social Worker cannot attend, communicate psychosocial, discharge and plan of care barriers to the appropriate Care Manager for discussion, as necessary meet with the CM after the meeting to obtain updates and action items.
3. Complex Care Meeting - Attend weekly Complex Care Meeting (CCM) and discuss high risk patients. Formulate potential solutions with Utilization Manager and Social Worker and continuously monitor cases/follow up on all action items. Proactively identify high risk cases that need to be escalated to the list that are not scheduled for discussion that week. Complete CCM follow-up after the meeting as assigned
4. New Consults - Complete and document a psychosocial assessment within 24 hours of receiving the consult and communicate recommendations back to the Care Manager/Multidisciplinary Team. Determine and document a plan of care as a part of the psychosocial assessment in Epic™
5. Active Consults - Document social work note/reassessment as outlined per policy. Discuss with appropriate members of the multidisciplinary team when there are barriers to discharge and psychosocial concerns impacting progression of care or readmission risk. Coordinate family meetings, as necessary, to support the progression of care. Provide education on community resources, support/educational groups, and any other appropriate resources to patient, family, and care team. Educate and/or coordinate referrals to community resources and post-acute providers as necessary. Identify patient’s readiness to discharge based on discussions with the patient/family/care team on an ongoing basis. Assess the discharge plan to determine needs post-discharge and communicate to patient/family/care team on an ongoing basis. Identify required authorization for post-discharge services and refer to the appropriate post-discharge service provider. Participate in medication resource management for non-resourced patients, as needed. Verify patient’s understanding/agreement of discharge plan. Refer administrative tasks (e.g., faxing, form processing) to Care Management Assistant. Escalate urgent or complex cases to appropriate Care Management leadership according to established departmental escalation process.
6. Professionalism - Demonstrates flexibility and professionalism in a dynamic environment with frequent re-ordering of priorities and assignments. Uses critical thinking skills to evaluate and prioritize rapidly changing demands, working collaboratively to best accomplish the team’s mission.
7. Documentation - Documents activities, events, and information per standards in established software systems in a timely, accurate, and complete manner. Identifies Avoidable Delays and documents causes for delay consistent with department standards.
8. Confidentiality - Uses established policies and processes to handle, discuss, and transmit protected health information in manner consistent with privacy and compliance expectations and policies.
9. Compliance and Performance Improvement - Uses departmental guidelines and job aids to perform work in an accurate, compliant manner consistent with known and written expectations and work rules. Participates in process improvement initiatives, which may include helping with the creation/revision of guidelines, training tools, and job aids. Maintains current knowledge of institutional and departmental expectations for job performance through attendance at meetings, review of meeting minutes and guidance documents, and independent review of institutional and departmental policies and guidelines as needed. May assist with training/pre-cepting as needed as assigned.
1. Bachelor's Degree in Social Work is required. Master's Degree is preferred.
2. A minimum of 2 years of experience in a human services related field.
3. LCSW certification is preferred.
4. Current BCLS certification.
Legal Employer: Nash Hospitals
Entity: Nash UNC Health Care
Organization Unit: CPH Social Work
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Schedule: Day Job
Location of Job: NASH HC
Exempt From Overtime: Exempt: Not Applicable
The UNC Health System and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.
UNC Health is an equal opportunity and affirmative action employer.
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
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