Summary GENERAL SUMMARY: Leads and facilitates the collaborative management of patient care across the continuum, providing social work services, comprehensive care assessments and arranging appropriate level of care based on discharge criteria, in order to achieve the best possible patient outcomes and experience. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Directly contributes to the creation of an outcomes-based patient care delivery system that is a planned process involving service coordination, monitoring and management to achieve quality clinical outcomes, patient/physician/payor satisfaction and cost-effective utilization of resources. 3. *Maintains and enhances payor relationships. 4. *Assesses, plans, monitors and coordinates plan of care from pre-admission to community re-entry through the implementation of care management standards and processes. 5. Interviews patient(s) and family members to assess psychosocial needs including: level of function, cultural and ethnic factors, emotional status, social skills, family relationships, financial / insurance status, response to illness or current conditions affecting patient. 6. *Coordinates patient/family meetings and acts as the patient advocate; provides patient and family members with accurate information regarding patient rights policy, advance directives, guardianship rights, power of attorney, etc. 7. Interprets psychosocial information to attending physician and other patient care team members, as appropriate, by completing the social work assessment and documenting the information in the patients medical chart. 8. *Counsels patient and family members regarding issues such as: anxiety and stress precipitated by illness/hospitalization, coping with physical impairment/disability, fears related to helplessness or death, adjustment to the need for institutional or specialized care, etc. 9. Involves patient and family members, as appropriate, in care plan development and process by meeting with them to discuss recommendations made by the healthcare team; attends interdisciplinary team meetings in order to provide social work input regarding care plan process and development and to ensure a comprehensive and holistic approach to care provided. 10. Demonstrates knowledge of the principles of growth and development and the skills necessary to provide age specific and appropriate care of the patient according to their age category; interprets data about the patients status in order to identify each patients age specific needs consistent with the care of the patient. 11. Presents patient with discharge options so patient and family members can make informed choices. 12. Contacts nursing homes, community/state/federal resources on patients behalf to obtain and utilize services; may assist with making patient transfers by notifying facility of referral, notifying family of transfer, arranging transportation, processing documents/records, obtaining financial assistance, i.e. Medicare / Medicaid, etc. 13. May identify and assess possible victims of abuse or neglect and notify proper legal authorities as required. 14. *Proactively communicates with payor source to explore coverage solutions. 15. Utilizes rehabilitation/LTCH/SNF criteria to promote optimal outcomes for the patient within the boundaries of the diagnosis. 16. Coordinates and facilitates treatment team meetings, plan of treatment, as appropriate. 17. Proactively collaborates with the health care team, payors, community agencies, providers and legal representatives to ensure continuity throughout the continuum. 18. Serves as a liaison with the treatment team and the Primary Care Physician, referring physician, medical director, patient/caregiver(s) and other parties as appropriate. 19. Participates in planning of social work services in selected hospital programs i.e. case management, outpatient social work services, etc. 20. Records, documents, compiles and maintains monthly statistics on patients served; participates in various projects as assigned. 21. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 22. Participates in meetings, committees and department projects as assigned. 23. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk *. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patients growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of computer hardware equipment and software applications relevant to work functions. 3. Knowledge of organizational and human resource management standards and practices. 4. Knowledge of performance improvement, budgetary and financial methods and practices. 5. Knowledge of management and leadership principles and practices. 6. Skill in conflict diffusion and resolution. 7. Ability to communicate effectively both verbally and in writing. 8. Ability to perform crucial conversations with desired outcomes. 9. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 10. Ability to problem solve and engage independent critical thinking skills. 11. Ability to maintain confidentiality relevant to sensitive information. 12. Ability to prioritize work demands and work with minimal supervision. 13. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Bachelors in Social Work required. Masters degree in Social Work required. Licensure as a Licensed Clinical Social Worker (LCSW) by the State of Nebraska required. MSW preferred. Two (2) years of experience in the Healthcare social work/case management field preferred. Discharge planning experience required. OR Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Bachelors degree required, masters degree preferred. Two (2) years of experience in the Healthcare social work/case management field preferred. Discharge planning experience required. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. Case Management certification preferred.