Identifies patients presenting in the Emergency Department who have had a previous acute care admission at FMH within the past 6 months and evaluates those patients for potential of medically valid acute care admission prevention program to reduce unnecessary hospital readmissions. Identifies community resources and interventions on behalf of the patient and collaborates with the multidisciplinary healthcare team to modify plan of care, as needed, as key clinical and financial information is identified. Demonstrates knowledge of resources available and utilizes them effectively in discharge preparations. Documents case management plan including assessment, plan of care, interventions, and appropriate resources by the end of each working shift to ensure a complete and accurate medical record. Communicates effectively with patients, family members, physicians, insurance companies, other providers, community agencies, staff and peers to provide efficient and successful patient transitions through the continuum. Collaborates with the healthcare team in providing client/family education related to the patient's diagnosis and return to health. Provides community outreach to physician offices, home care, patients and caregivers to avoid readmission and Emergency room visits.
POSITION REQUIREMENTS: Bachelor or graduate degree from a social work program accredited by the Council on Social Work Education or in a related field. Licensed as a Social Worker in the State of Maryland or actively pursuing to obtain license within 6 months of hire. 3-5 years of medical acute care experience, acute hospital preferred. Experience in performing case management, utilization review, discharge planning, or quality/performance improvement review preferred. Knowledgeable of community resources. Demonstrates tact, diplomacy, negotiation skills, customer relations and ability to present a professional presence and appearance. Basic knowledge of clinical and psychosocial aspects of patient care.