Continuing Care Manager - Social Worker

Overview

The inpatient Palliative Care social worker facilitates psychosocial assessments and clinical interventions with patients and families navigating serious illness and end-of-life at the Jack Byrne Center and Dartmouth-Hitchcock Medical Center.

Responsibilities

• Manages and coordinates interdisciplinary care of defined populations through the care continuum from wellness through end of life from a psychological, social and environmental perspective.

• Identifies high risk patients requiring on-going coordination of care; performs a comprehensive patient/family assessment, develops a comprehensive treatment plan that will span the continuum of psychosocial issues, implements a plan of care to provide continuing support and coordination for patient/family with multiple complex system needs, manages benefits and negotiates continuing care services for enrollees in various health insurance plans, etc.

• Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in regards to psychological, social and environmental areas.

• Monitors the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.).

• Shares assessment and psychological, social and environmental care plan data with patient/family consent as the patient moves through different care settings.

• Identifies gaps in the care continuum and work with the community and provider networks to expand access to needed psychological, social and environmental services.

• Participates in the development of disease management strategies and identifies the appropriate measures for the evaluation of outcomes.

• Participates in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization.

• Collects and evaluates data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization.

• Performs other duties as required or assigned.

Qualifications

• Master’s Degree in Social Work (MSW) with 5 years of clinical experience required.

• Critical thinking skills, strong leadership and communication abilities, the ability to be a self-starter, negotiate, and handle conflict resolution desired.

• Understanding of and comfort using computers desired.

• Collaborative team player, use of systems approach in planning, problem solving and decision making, creativity, innovation, risk taking, autonomy, flexibility, receptiveness to change and a commitment to professional growth desired.

Required Licensure/Certifications

• None