SW Transitions And Care Coordinator Full Time
Cape Fear Valley Health
Summary
Provides CAP case management that consists of assessing, care planning, referral and linkage, monitoring and regular follow up. Case managers will identify needed medical, social, environmental, financial, and emotional interventions. Responsible for overseeing the maintenance of community integration while ensuring the beneficiary's health, safety and wellbeing. Consistently communicate with local, region and state resources to ensure mental, spiritual, medical and social needs are met. Required to provide crisis interventions to encourage adherence to long term medical and mental health care.
Job description
Major Job Functions
- Provides case management and care coordination activities to assigned caseload in a manner that maximizes patient satisfaction, provider satisfaction and client centered outcomes
- Coordinates Money Follows the Person Transitions as well as Community Transitions such that the length of stay in acute care, or other qualifying level of care is reduced, appropriate supports are put in place, and readmissions are avoided
- Performs comprehensive interdisciplinary needs assessments for the assigned CAP beneficiaries monthly
- Formulates the plan of care in collaboration with the beneficiary and support persons with the service plan specifying person-centered goals, objectives, and formal as well as informal support services to address identified medical and functional care needs
- Provides follow-up visits and/or other support to beneficiaries who have been discharged from acute care or SNF to reduce the possibility of readmission
- Provides referral and linkage activities to connect a beneficiary or caregiver with medical, behavioral, social, and other programs, services and supports to mitigate identified needs and achieve whole person-centered goals
- Completes documentation via eCAP internet-based program
- Responsible for SBARR communication with acute care staff when CAP beneficiaries are hospitalized and performs as a liaison for discharge planning as needed
- Develop resources to serve the assigned population through grants, networking with outside agencies and other departments within the Health System and through other approved means
- Other duties as assigned
Minimum Qualifications
Education and Formal Training
- Master's degree in Social Work (MSW) required
- National Certification in Case Management or Licensed Clinical Social Worker preferred
- Maintain State requirements for population served when performing CAP/DA, CAP/C, CAP/Choice or MFP transitions or case management required
Work Experience
- 1 year previous experience in medical social work, case management, disease management transitions coordination, or care coordination required
Knowledge, Skills, and Abilities Required
- Proficiency in reading, writing, and speaking the English language
- Ability to work with high degree of independence, demonstrating personal accountability, responsibility for performance improvement and high professional growth
- Positive interpersonal skills with excellent communication, problem solving and negotiation skills
- Strong organizational skills, critical thinking skills, and the ability to appropriately prioritize direct case management, patient/family support and other duties
- Knowledge of Erickson's developmental model and ability to demonstrate age specific interventions
- Knowledgeable and sensitive to the psychosocial spiritual and cultural needs of individuals
- Articulate orally and in written communication and ability to make accommodations for literacy and comprehension levels
Physical Requirements
- Ability to use own transportation to make home visits and to carry out duties away from the office
- Visual acuity to see and read medical records documents, computer screens and computer printouts
- Speech and auditory abilities are required to allow for effective communication
- Ambulate, climb stairs and push or pull wheelchair patients at times
- Ability to lift, load/unload client care supplies/equipment up to 30 pounds
- Position may involve contact with blood or potentially infectious material
Required Licenses and Certifications
CCM - Commission For Case Manager Certification
Requirements
- Master's degree in Social Work (MSW) required
- National Certification in Case Management or Licensed Clinical Social Worker preferred
- Maintain State requirements for population served when performing CAP/DA, CAP/C, CAP/Choice or MFP transitions or case management required
- 1 year previous experience in medical social work, case management, disease management transitions coordination, or care coordination required
- Proficiency in reading, writing, and speaking the English language
- Ability to work with high degree of independence, demonstrating personal accountability, responsibility for performance improvement and high professional growth
- Positive interpersonal skills with excellent communication, problem solving and negotiation skills
- Strong organizational skills, critical thinking skills, and the ability to appropriately prioritize direct case management, patient/family support and other duties
- Knowledge of Erickson's developmental model and ability to demonstrate age specific interventions
- Knowledgeable and sensitive to the psychosocial spiritual and cultural needs of individuals
- Articulate orally and in written communication and ability to make accommodations for literacy and comprehension levels
- Ability to use own transportation to make home visits and to carry out duties away from the office
- Visual acuity to see and read medical records documents, computer screens and computer printouts
- Speech and auditory abilities are required to allow for effective communication
- Ambulate, climb stairs and push or pull wheelchair patients at times
- Ability to lift, load/unload client care supplies/equipment up to 30 pounds
- Position may involve contact with blood or potentially infectious material
- CCM - Commission For Case Manager Certification
Company overview
Cape Fear Valley Health is a comprehensive regional healthcare system based in Fayetteville, North Carolina, serving southeastern North Carolina and surrounding regions. Established in 1956, it has grown to become North Carolina's 8th largest health system, operating as a private not-for-profit organization with 7,500 employees and over 1,000 physicians. The system encompasses eight hospitals with 988 total beds, including Cape Fear Valley Medical Center, Highsmith-Rainey Specialty Hospital, Bladen County Hospital, Hoke Hospital, and Harnett Health facilities. Annually, the system serves more than 1 million inpatient and outpatient visits across its network of over 150 locations. Cape Fear Valley Health specializes in cardiac care, cancer treatment, surgical services, neuroscience, pediatrics, rehabilitation, orthopedics, and behavioral health. The organization has earned numerous national recognitions including Healthgrades Top 100 Hospital for Cardiac Care, IBM Watson Top 50 Cardiovascular Hospital, and The Leapfrog Group Grade-A for Patient Safety. With a mission to provide exceptional healthcare for all patients, the system emphasizes patient-centered care, innovation, and community service while maintaining multiple disease-specific certifications from The Joint Commission.