Job Shift: Days Job Type: Per Diem The individual in this position 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 to assess the patient for transition needs including identifying and assessing patients at risk for readmission. Conducts complex psycho-social assessment and interventions 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 sequenced and provided at the 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 • Participates in planning the social work component required in selected hospital programs • Provides in-service education for staff • Collaborate with community providers to develop educational resources appropriate for staff and patients/patient representatives This individual’s responsibility will include the following activities: a) complex psycho-social transition planning assessment and reassessment and intervention, b) assistance with adoptions, abuse and neglect cases, including assessment, intervention and referral as appropriate to local, state and /or federal agencies, c) care coordination, d) implementation or oversight of implementation of the transition plan, e) leading and/or facilitating multi-disciplinary patient care conferences including Complex Case Review, f) making appropriate referrals to other departments, g ) communicating with patients and families about the plan of care, h) collaborating with physicians, office staff and ancillary departments, i) assuring patient education is completed to support post-acute needs , j) timely, complete and concise documentation in Tenet Case Management documentation system, k ) maintenance of accurate patient demographic and insurance information, l) and other duties as assigned. Required qualifications include: • Master in Social Work (MSW). • Must be currently licensed, certified, or registered to practice profession as required by law or regulation in state of practice or policy. • Active license for state(s) covered. Preferred: Accredited Case Manager (ACM). Minimum of two years acute hospital experience preferred. Required skills include: • Demonstrated organizational skills • Excellent verbal and written communication skills • Ability to lead and coordinate activities of a diverse group of people in a fast paced environment • Critical thinking and problem solving skills and computer literacy.