Social Work Case Manager
Current» Complete case management comprehensive assessments to gather information regarding patients’ physical and mental health baselines prior to their admission to the acute care facility by utilizing the facility-mandated inpatient case management bio-psycho-social screening tool.» Facilitate communication between patients and members of their treatment team, ranging from patient attendings, registered nurses, patient care technicians, and other physicians providing patients’ care. » Create an adhesive streamline of communication between social work case managers and other members of patients’ treatment team by sustaining sufficient documentation in Epic that is palpable, with most up-to-date information, pertinent to case management’s role in patient’s plan of care and discharge planning. » Utilize the” Case Management Navigator” tool located in Epic to report patient’s previous mental/physical baseline prior to admission to acute care facility, any current home health, homemaker, or outpatient therapy services prior to patient’s admission to acute care facility, patient decisional status, healthcare power of attorney/healthcare surrogacy documentation, and mandated Medicare inpatient IMM and MOON letter deliveries.» Communicate with the appropriate healthcare professionals such as patient primary care providers, health care insurance companies, home health/nursing facility liaisons, durable medical equipment companies, as well as home infusion companies. » Assist registered nurses and attendings in discharge planning processes for patients, including facility placements as well as coordinate home health and home infusion services for patients discharging home with post-hospital rehabilitation needs.» Arrange transportation for patients discharging from acute care facility, justifying their medical need for ambulance transportation by completing, faxing, and documenting using the required Physician Certification Statement or PCS forms.
