Social Worker Transitions and Care Coordinator

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Community Alternatives Program Services

Job Family

Professional

Work Shift

Days (United States of America)

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.

Major Job Functions

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:

• 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

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Master’s degree in social work (MSW) required OR 10 years of relevant work experience”.
• 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

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity