Summary

JOB SUMMARY

Restores patients to optimum health and social adjustment, while facilitating a positive impact on the hospital transition of care; informs the healthcare team of the patient's social, emotional, environmental, and financial needs and resources that may influence their treatment options and discharge plan; assists case manager nurses with complex social situations and discharge planning.

DUTIES & ESSENTIAL JOB FUNCTIONS

NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

• Collaborates with Care Transition team and Health Advocates for high-risk patients for timely follow-up appointments and confirms prior to discharge that complex patients are appropriately linked to community services.
• Coordinates patient care activities with other members of the healthcare team, the patient, the patient's representatives, and community partners and makes referrals as appropriate.
• Effectively intervenes in suspected abuse/neglect cases and in complex or high-risk situations as requested; is competent to identify and intervene with high-risk behaviors, responding to traumas.
• Identifies and mobilizes patient and family strengths to optimize the use of healthcare and community resources; in coordination with patient and family wishes, guides/assists in securing needed post-discharge services which may require negotiating for services covered but not readily available; provides consultation and education to team members regarding patient/family (psychosocial and discharge planning) issues and community resources.
• Identifies potential problems, prevents and or resolves variances to the care management plan; assesses and coordinates family and community resources to meet identified needs to support the discharge plan.
• Intervene with patients and patient representatives regarding emotional, behavioral, and financial barriers to current illness and/or disability.
• Leads patient-centered conferences to meet the needs and desires of the patients.
• Maintains patient records including patient assessments, plans, interventions, patient/family involvement, outside agency communications and interdisciplinary contacts.
• Participates in discharge planning activities; effectively identifies and intervenes with high-risk discharge planning issues with psychosocial complexity; whether referred by other healthcare providers or identified through assessment. Assists Care Management Nurse with discharge planning efforts as requested; obtains or coordinates referrals for post-discharge service needs, if required; mobilizes resources to affect the rapid and timely movement of the patient through the system to achieve targeted discharge times established by AHS.
• Performs psychosocial assessment interviews with patients and/or families and records this assessment in the patient's medical record. Assesses patient's level of functioning, environment, appropriateness and adequacy of support system related to illness and ability to cope; reassesses the patient's condition when changes occur and revises the care plan when appropriate. Performs rapid assessments and develops crisis management plans for referral, evaluation and admission.
• Provides patient advocacy, including primary responsibility for initiating processes regarding capacity determinations, grief counseling, and conservatorship/guardianship; takes an advocacy leadership role regarding adoption/surrogacy cases.
• Refers and assists patients/families in applying for appropriate financial programs (CCS, SDI, SSI, SSD, private pensions) and legal instruments as needed.
• Screen for any barriers to care such as substance abuse, neglect, financial limitations or housing.
• Serves as a resource and provides counseling and treatment related to palliative care or end-of-life planning.

QUALIFICATIONS

Required Education: Master's degree in social work/welfare issued by a school accredited by the Counsel of Social Work Education.

Required Experience: Two years of Social work or Case Management experience in an acute setting or protective services.

Preferred Licenses/Certifications: Active certification in Case Management (ACM or CCMC), Current and valid license as a Clinical Social Worker issued by the State of California Board of Behavior Science Examiners. Bilingual preferred.

PAY RANGE

$53.13per hour

The pay range for this position reflects the base pay scale for the role at Alameda Health System. Final compensation will be determined based on several factors, including but not limited to a candidate's experience, education, skills, licensure and certifications, departmental equity, applicable collective bargaining agreements, and the operational needs of the organization. Alameda Health System also offers eligible positions a generous comprehensive benefits program.