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Job Summary
Accountable for professionally managing targeted patient populations in order to achieve efficient and effective care delivery. Includes coordinating, facilitating, monitoring and evaluating interventions to achieve desired outcomes. Functions as part of an interdisciplinary team to guide and track individuals across time and delivery sites. Provide social work services for targeted populations and serve as social work resource for department.Accountabilities
Facilitation of Patient Centered Care - 30%
1. Under supervision of Manager and in conjunction with patient/family and healthcare team, develops an initial Plan of Care that highlights actual and potential self management improvement opportunities.
2. Facilitates and monitors implementation of Plan of Care.
3. Coordinates patient/family participation in Plan of Care and self management.
4. Uses knowledge of community resources to facilitate achievement of goals.
5. Coordinates patient education to achieve Plan of Care.
6. Performs home visits as necessary to evaluate possible barriers to attainment of self management goals and develops strategies to overcome barriers.
Interdisciplinary Practice - 30%
1. Participates in the development and execution of the Plan of Care.
2. Demonstrates expertise in care management and serves as resource to the interdisciplinary health care team.
3. Integrates knowledge of external and internal regulatory requirements into the review and management of cases.
4. Works in collaboration with GHS Emergency Department and facility staff as necessary to provide continuity of care.
5. Serves as bridge across the clinical setting.
Evidence Based Care - 20%
1. Utilizes and incorporates knowledge of efficiency and effectiveness indicators (example-PQRI) when coordinating and facilitating Plan of Care.
2. Increases knowledge of best practices and clinical standards of care and incorporates knowledge into practice.
Measurements and Reporting - 10%
1. Documents in the medical record and on team tools, accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals.
Care Management Core Competencies - 10%
1. Adheres to nationally accepted standards of Case Management.
2. Demonstrates adaptability to new standards and to the evolution of workforce development activities.
Supervisory/Management Responsibilities
This is a non-management job that will report to a supervisor, director or executive.
Minimum Requirements
Masters Degree in Social Work
Required Certifications, Registries, Licenses
LMSW (Licensed Masters Social Worker) or LISW (Licensed Independent Social Worker) (Lawson code LLSW)
Optional
In lieu of the experience and/or educational requirements indicated above a combination of education, training, and/or experience will be considered an equivalent substitution: NA
Other Required Skills and Experience
Basic Computer Skills
Knowledge of office equipment (fax/copier)
Proficient computer skills (word processing)
Proficient computer skills (spreadsheets)
Other Qualifications or Experience
SC Driver's License and proof of current auto liability coverage - Required
Must be willing to travel and have reliable personal transportation - Required
1 year experience in healthcare experience - Preferred
Additional In Lieu of Statement
Team members employed in this job prior to July 1, 2020 are grandfathered under prior educational and experience requirements. In addition, team members must be certification eligible and will have one year to obtain required certification(s).
Work Shift
Day (United States of America)Location
CorporateFacility
7002 Value-Based Care and Network ServicesDepartment
70028455 Care TransformationShare your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.