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Knowledgeable about disease, treatment and psycho-social implications for individual patients and families as it pertains to their age and stage of psycho-social development; provides appropriate interventions and discharge planning services to patients and families; facilitates a smooth transition for the patient throughout the continuum of care by accessing hospital, community and governmental resources; pragmatic in approaching End of Life and ethical issues.
ASSESSMENT: Assesses constantly for best resource allocation with patient management activities both in hospital and community systems to advocate for cost containment without jeopardizing
patient quality efforts; Completes initial and ongoing assessment of the patient and family's response to the diagnosis, living environment and discharge planning needs; Identifies and reports appropriate discharge barriers and avoidable days in order to promote the resolution process within the hospital or community systems; Provides assessment for the source and significance of social, psychological, environmental, emotional, and economic factors that may contribute to the health and response to treatment of both inpatients and outpatients of all ages and documents appropriately in the medical record.
PLANNING: Actively coordinates patient and family interventions with the attending physician, patient, family, case managers, and other staff; Develops treatment plan based on the assessment and mutually agreed upon goals with the patient, family and physician; Develops a plan of intervention, which is integrated with the interdisciplinary treatment team to establish continuum of care in congruence with ethical and legal considerations; Advocates, mediates, and negotiates a cohesive plan for maintaining or improving social supports and patient safety
IMPLEMENTATION: Provides supportive counseling, education, and crisis management to patient/ family; Facilitates healthcare decision making and resolution of discharge planning issues; Provides psycho-social intervention for: neglect/abuse, adjustment to illness, bereavement, non-compliance and other psycho-social barriers to diagnosis and treatment; Maximizes health status and minimize length of stay and utilization of hospital resources; Provides referral and linkage to health care and community resources.
EVALUATION: Evaluates the effectiveness of interventions and actions in relation to the intended goals of the discharge plan; Revises intervention strategies and discharge plan as necessary; Identify barriers in service delivery systems and advocate for change; Evaluate patient outcomes and participate in process improvement.
COLLABORATION/CONSULTATION: Collaborate with interdisciplinary team to enhance quality of care and efficiency; Maintain a positive working relationship with healthcare team and community agencies and services; Assist interdisciplinary team in understanding significant social and emotional factors related to illness; Functions as a liaison for the patient and the facility both internally and externally. Maintains networks for professional growth and awareness; Works collaboratively with the health care team to facilitate the plan of care for inpatients and outpatients, as appropriate.
COMPLIANCE: Assures chart documentation consistently meets the department and hospital standards for accountability and confidentiality; Recognizes legal responsibilities and identifies area of concern to Risk Management and Legal Services; Maintains current knowledge and is familiar with federal and state regulator guidelines, institutional policies, and payer source policies; Documents interventions timely
PROFESSIONAL DEVELOPMENT: Attends appropriate clinical and professional organizations, workshops and meetings, Stays abreast of community resources available to facilitate safe patient transitions of care, Remains current on clinical advancements related to primary patient population, Proactively seeks to understand areas/roles outside of immediate area/role within department.
Other Knowledge, Skills and Abilities Required:
Casework principles, including diagnosis, assessment, crisis intervention, and treatment planning; techniques in individual and family supportive counseling; knowledge of community resources, public assistance systems, Medicare/Medicaid; accepted professional, ethical, and regulatory standards within the existing medical community and professional organizations.
Certifications: Case Management certification (ACM, CCM, C-SWCM, C-ASWCM)
Other Knowledge, Skills and Abilities Preferred:
Ability to prioritize many simultaneous demands and tolerate frequent interruptions. Self-awareness, professionalism, and good judgement when addressing emotional and confidential issues. Excellent verbal and written communication.
Mercy Health is an equal opportunity employer.
We'll also reward your hard work with:
Comprehensive, affordable medical, dental and vision plans
Prescription drug coverage
Flexible spending accounts
Life insurance w/AD&D
An employer-matched 403(b) for those who qualify.
Paid time off
And much more
Scheduled Weekly Hours:
Days/Afternoons (United States of America)
All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health Youngstown, Ohio or Bon Secours Ashland, Kentucky, which is an Affirmative Action and Equal Opportunity Employer, please email email@example.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at firstname.lastname@example.org