Social Worker II - Case Management

Overview

Job Summary

Desert Regional Medical Center is a 385 bed acute-care hospital classified as a stroke receiving center and level 2 trauma facility with an innovative , patient centered and evidence-based Rehabilitation Services Department. Our compassionate team provides a wide range of inpatient and outpatient services, including acute care rehabilitation, joint replacement & spinal surgery, neurosurgery, ICU, Telemetry, step-down care, skilled nursing, as well as outpatient therapy, hand and lymphedema clinics.

Summary

• The Social Worker is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination.
• The individual in this position has overall responsibility for to assess the patient for transition needs including identifying and assessing patients at risk for readmission.
• Conducts complex psycho-social assessment and intervention to promote timely throughput, safe discharge and prevent avoidable readmissions.
• This position integrates national standards for case management scope of services including:
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to physicians, patients, families and caregivers •Leads a population of patients by service line and/or leads the team by being a resource to Tenet performance standards.

Responsibilities
This individual’s responsibility will include the following activities:

• Complex psycho-social transition planning assessment and reassessment and intervention,
• Assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies,
• Care coordination, d) implementation or oversight of implementation of the transition plan,
• Leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review,
• Making appropriate referrals to other departments, g ) communicating with patients and families about the plan of care,
• Collaborating with physicians, office staff and ancillary departments, I) assuring pat