About this role
The Social Worker facilitates care across the continuum by coordinating resources and ensuring patients receive appropriate-level care based on medical necessity. The role focuses on psycho-social assessment and intervention, transition planning, safe discharge, and preventing avoidable readmissions within a per diem rotate shift environment.
Key Responsibilities
- facilitate care continuum through resource coordination
- conduct complex psycho-social assessment and intervention
- assess transition needs for timely throughput and safe discharge
- lead/facilitate multi-disciplinary patient care conferences including Complex Case Review
- complete timely, concise documentation in Case Management system
Technical Overview
This role operates in hospital case management workflows, including transition management, care coordination, documentation in a Case Management system, and participation in complex case review. It requires compliance with TJC accreditation standards plus state and federal regulatory requirements and Tenet policy, while collaborating across clinical and ancillary teams.
Ideal Candidate
The ideal candidate is a per diem social worker who can manage care along the continuum through case management, transition planning, and resource coordination. They should be strong in complex psycho-social assessment and intervention, safe discharge planning, readmission prevention, and be able to document accurately in a Case Management system while collaborating in multi-disciplinary conferences.
Must-Have Skills
Conduct complex psycho-social assessment and interventionAssess patient for transition needs to promote timely throughputsafe discharge and prevent avoidable readmissionsComplete documentation in Case Management system
Tools & Platforms
Case Management systemTEMPO
Required Skills
transition managementcare coordinationthroughput efficiencymedical necessity assessmentpsycho-social assessmentpsycho-social interventionsafe dischargereadmission preventionutilization of resourcescase managementcomplex case reviewmulti-disciplinary patient care conferencesreferralsadoptionsabuse and neglect case assessment and referralpatient educationCase Management system documentationpatient demographic and insurance information maintenanceprecept new staff membersTEMPOTJC accreditation standards compliancestate and federal regulatory requirementsTenet policy compliance
Hard Skills
transition managementcare coordinationthroughput efficiencymedical necessity assessmenttransition planning assessment and reassessmentpsycho-social assessmentpsycho-social interventionsafe discharge planningreadmission preventionutilization of resourcesresource coordinationcase managementcomplex case reviewmulti-disciplinary patient care conferencesreferrals to other departmentsadoptionsabuse and neglect casesassessmentintervention and referral to local/state/federal agenciesTEMPOpatient educationdocumentation in Case Management systemmaintenance of patient demographic and insurance informationprecepting new staff membersTJC accreditation standards compliancestate and federal regulatory requirements complianceTenet policy compliance
Soft Skills
resource coordinationpatient and family communicationcomplex psycho-social assessment and interventioncollaboration with physiciansoffice staff and ancillary departmentsleading and facilitating multi-disciplinary conferencessupportivecollaborative environmentdocumentation accuracyconflict-sensitive judgment (implied by abuse/neglect case work)
Keywords for Your Resume
Social WorkerJob Shift: RotateJob Type: Per Diemper diemcase managementtransition managementcare coordinationthroughputsafe dischargereadmission preventionmedical necessitypsycho-social assessmentpsycho-social interventioncomplex case reviewmulti-disciplinary patient care conferencesreferralsabuse and neglectadoptionspatient educationCase Management systempatient demographicinsurance informationTJC accreditation standardsstate and federal regulatory requirementsTenet policyTEMPOprecepts new staff members
Deal Breakers
Must be able to conduct complex psycho-social assessment and intervention, Must be able to perform assessment for transition needs and support safe discharge/readmission prevention, Must be able to complete timely, concise documentation in the Case Management system, Must be willing/able to participate in rotate per diem shift schedule
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