Facility
Cape Fear Valley Medical CenterLocation
Fayetteville, North CarolinaDepartment
Coordination of CareJob Family
ProfessionalWork Shift
Days (United States of America)Summary
Comprehensively plans for services for a targeted population. Responsible for psychosocial assessments, crisis intervention, discharge planning, and coordination of referrals and resource information to patients and families in need of assistance. Independently identifies complex patients as well as receives referrals from nursing and other ancillary staff. Provides an array of social work services to patients and families to promote understanding and resolution of problems related to environmental stress, physical illness, interpersonal conflicts, and other psychosocial issues. Adheres to the patient experience initiatives and champions customer service. Works collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum at the appropriate level of care.The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:
Conducts face-to-face interviews with patients and family members to develop therapeutic relationships and obtain psychosocial and financial information necessary for the facilitation of appropriate discharge planning
Performs proactive screenings and assessments for patients’ clinical, psychosocial, and discharge planning needs
Documents assessment, the on-going plan, case progress, intervention(s), and reassesses patients as needed
Initiates referrals and recommends consults to enable patient to be prepared for safe and timely discharge or transfer
Assists patient/family in coping with hospitalization, disability, and chronic/terminal illness
Utilizes communication, negotiation, and advocacy skills with patient, family, healthcare team and community
Provides information, education to patient/family on community resources and options for post-acute care appropriate to the age of the patient served
Carries out discharge planning activities to include providing arrangements for Home Health, Hospice, Home Infusion, DME, Outpatient Hemodialysis, Rehab, LTAC, Assisted Living, Rest Home and Skilled Nursing Facility placements
Provides alternate plan of care options at the appropriate level of care based on patient/family needs and in collaboration with physician and/or designated team members
Serves as a resource for processing issues such as guardianship, abuse, neglect, power of attorney, healthcare surrogate, advance directives or psychiatric involuntary commitment. Initiates/completes forms required for post-acute placement.
Serves as a reliable resource for the Acute Care Nurse Navigator for difficult placements, information on Medicaid and disability, and Department of Social Service Referrals
Consults with the Acute Care Nurse Navigator when clinical explanation of disease processes, clarification of physicians’ orders, and other pertinent information is needed to determine, safe appropriate discharge plan
Other duties as assigned
The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:
Master’s Degree in Social Work required
Licensed Social Worker in North Carolina required
Professional Certification in Case Management or Social Work (CSW, CCM, or ACM) preferred
1 year experience in Social Services, Home Health, Hospice or Acute Care setting required
Acute Care Case Management experience preferred
Flexible with scheduled hours to meet the needs of the department, unit, patient and family
Work is not standardized and requires a high degree of prioritization skills
Excellent interpersonal communication and negotiation skills
Ability to communicate effectively and work with people of all social, economic and cultural background
Proven written, telephonic and electronic communication skills
Assertive and persuasive in interactions with customers, peers, management and core staff served
Strong organizational and time management skills
Proficiency with various computer programs including Microsoft Office, Midas, ProviderLink, ValleyLink, eHIM, and SMS
Ability to demonstrate respect and team building
Flexible, open-minded and adaptable to change
Ability to work collaboratively with department staff, physicians and healthcare professionals at all levels to achieve established goals, improve quality of outcomes, maintain or exceed Joint Commission standards and State mandates as they apply to the department operations
Light carrying and lifting may be required
Walking may be required to access all areas of the Medical Center
Ability to effectively communicate orally to patients, family members, personnel and physicians
Visual acuity to proofread hand or typewritten materials
Manual ability to use telephones and computer keyboard
Required Licenses and Certifications
LCSW - NC Social Work Certification And Licensure BoardCape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity