Description Social Work Care Manager AdventHealth Orlando Location Address: 601 E Rollins St, Orlando, FL 32803 Top Reasons to work at AdventHealth Orlando Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando serves as the major tertiary facility for much of the Southeast, the Caribbean and South America AdventHealth Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year Work Hours/Shift:
• Per Diem, 12 hour shifts, Must be avaialble to work 4 shifts in a six week period and one must be a weekend You Will Be Responsible For: Psychosocial Assessment and interventions Receives referrals for psychosocial complex needs from the health care team.
Provides assessment and reporting interventions in child abuse/neglect, domestic violence, adult/elderly abuse, child protection, sexual assault, and human trafficking as appropriate.
Provides consult services for patients who may possibly lack decision making capacity.
Follows the guardianship (temporary/ permanent) policies and procedures and coordinates with Care Management leadership throughout the process Provides consult services for foster care and adoptions Assists the health care team in the patient assessments and placements for mental health services Facilitates full team discussion including patient and family when ethical dilemmas arise Promotes the understanding and use of advanced directives and ensures patient preference and care goals are followed Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures.
Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, therapy notes, ED notes, test results and progress notes Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team Incorporate clinical, social and financial factors into the transition of care plan.
Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient’s readmission risk scores and coordinating readmission mitigation interventions Assures Social Work consults are completed for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination Escalates issues barriers to appropriate level of Care Management leadership Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR Facilitates patient care conferences with multidisciplinary team as needed.
Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care Ensures reassessment of discharge needs provided anytime a patient’s condition changes and/or the circumstances impacting the provision of post-hospital care changes Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
Communicate with patient/family the possible need to pay for services out of pocket Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
Participates in department and hospital Performance Improvement activities.
Provides necessary patient care coverage and assistance with other duties as assigned when needed Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
Participates in facility and department regulatory and certification preparations.
Social Work Care Manager serves as a preceptor Social Work Care Manager participates in department education (bulletin or presentation) with topic and content approved by Facility CM Director Qualifications EDUCATION AND EXPERIENCE REQUIRED: Masters in Social Work (MSW) Minimum three (3) years experience in hospital/medical social work EDUCATION AND EXPERIENCE PREFERRED: Care Management discharge planning experience Knowledge of state and federal guidelines pertinent to care management LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED: Licensed Clinical Social Worker (LCSW) ACM/CCM certification This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.