About this role
The Social Worker facilitates care across the continuum through coordinated resources, transition planning, and discharge support. The role performs complex psycho-social assessment and intervention to promote timely throughput, safe discharge, and prevent avoidable readmissions.
Key Responsibilities
- a) care coordination, b) transition planning assessment and reassessment, c) implementation or oversight of transition/discharge plan, g) leading/facilitating multi-disciplinary patient care conferences including Complex Case Review, m) timely complete and concise documentation in Case Management system
Technical Overview
Role focuses on hospital case management workflows: transition management, care coordination, discharge planning, multidisciplinary conferences (Complex Case Review), and structured documentation in a Case Management system, including using TEMPO as needed.
Ideal Candidate
The ideal candidate is an experienced social worker in a hospital setting who can lead case management across the continuum of care. They are strong in complex psycho-social assessment, transition planning, and coordinating multidisciplinary discharge and throughput to prevent avoidable readmissions.
Must-Have Skills
complex psycho-social assessmentcase managementsafe dischargereadmission preventiontimely complete and concise documentation in Case Management systemcompliance with state and federal regulatory requirementsTJC accreditation standardsTenet policy
Tools & Platforms
Case Management systemTEMPO
Required Skills
case managementresource coordinationcare coordinationtransition managementtransition planning assessment and reassessmentcomplex psycho-social assessmentpsycho-social interventionsafe dischargereadmission preventionutilization of resourcesmedical necessitymulti-disciplinary patient care conferencesComplex Case Reviewpatient educationabuse and neglect assessmentadoptions assessmentreferralsdocumentation in Case Management systemmaintenance of patient demographic and insurance informationTEMPO
Hard Skills
case managementresource coordinationcare coordinationtransition managementtransition planning assessment and reassessmentcomplex psycho-social assessmentpsycho-social interventionimplementation or oversight of implementation of the transition/discharge plansafe dischargereadmission preventionutilization of resourcesmedical necessitydischarge planningmulti-disciplinary patient care conferencesComplex Case Reviewpatient educationadoptions assessmentabuse and neglect cases assessmentabuse and neglect interventionreferrals to other departmentstimely complete and concise documentation in Case Management systemmaintenance of accurate patient demographic and insurance informationcare coordinationTEMPO
Soft Skills
patient advocacycommunication with patients and familiescross-functional collaborationcollaboration with physicianscollaboration with office staffcollaboration with ancillary departmentseducational delivery for physicianspatientsfamilies and caregiversin-service educationresourcefulnessmultidisciplinary facilitationproblem-solvingself-determination support
Keywords for Your Resume
Social WorkerCase Managementcase managementtransition managementcare coordinationtransition planningdischarge planningreadmission preventionsafe dischargemedical necessitypsycho-social assessmentpsycho-social interventionmulti-disciplinary patient care conferencesComplex Case ReviewTJC accreditationpatient educationabuse and neglectadoptionsCase Management systemTEMPO
Deal Breakers
Must be able to complete complex psycho-social assessment and intervention, Must be able to perform timely documentation in a Case Management system, Must follow state/federal regulatory requirements, TJC accreditation standards, and Tenet policy
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