Description
US:NV:Carson City Integrated Care Management
Full Time Day Shift
About Carson Tahoe Health
CTH is a not-for-profit healthcare system with 240 licensed acute care beds, fully accredited by the Center for Improvement in Healthcare Quality (CIHQ). CTH was voted 5th most beautiful hospital in the nation nestled among the foothills of the Sierra Nevada in North Carson City and only a short drive away from world-famous Lake Tahoe & Reno. We serve a population of over 250,000 and feature two hospitals, two urgent cares, an emergent care center, outpatient services and a provider network with 19 regional locations.
Summary
- This individual is responsible to facilitate care through the continuum utilizing effective resource coordination to promote optimal access to care balancing the patients’ resources and right to self-determination
- The overall responsibility to assess the patient for transition of care needs and risk for readmission
- This individual will be able to conduct complex psycho-social assessments and provide interventions to assist with throughput, safe discharges and avoid readmissions
Responsibilities
Transition Management
- Completes initial /comprehensive assessment within 24 hours of admission, including anticipated transition (discharge) plan
- Provides psycho-social assessment and intervention for patients identified with behavioral health issues, lack of social support systems, financial barriers, end of life and plan of care adherence
- Ensures plan of care and interventions are implemented and communicated to health care team, patient/family and post-acute care providers
- Complete timely, accurate and concise documentation in the EMR
Care Coordination
- Screens high risk and referred patients for psycho-social issues/barriers, that may impact the transition plan and intervenes as appropriate
- Assists with adoption/abuse/neglect cases and reports to appropriate external agencies as required
- Collaborates with patient/family/health care team to ensure patient preferences and choices are taken into consideration within the limitations of available resources
Education
- Ensure patient/ family receive education appropriate to their specific discharge plan
- Provides education to medical and nursing staff regarding relevant issues related to transition plan
Compliance
- Ensures compliance with local, state and federal regulations and accreditation requirements
- Operates within social work scope of practice as defined by the state licensing board
Complex Case Management
- Completes clear, concise and accurate initial/discharge planning/complex psycho-social assessments and reassessments per departmental guidelines (assessments within 24 hours of admission, reassessments every 3 days or as needed for change)
- Escalates barriers to transition planning per departmental escalation plan
- Completes post-acute referrals within 3 days of admission
- Schedules and facilitates complex case patient/family conferences as needed (at a minimum of weekly)
Qualifications
Required:
- Bachelor in Social Work from accredited school of Social Work
- Excellent interpersonal, written and verbal communication skills
- Demonstrated organizational skills, critical thinking and problem solving skills and computer literacy
- Unrestricted Social Worker license (LSW) in the State of Nevada
Preferred:
- Master in Social Work from accredited school of Social Work
- Two (2) years of acute care coordination experience
- Ability to obtain Accredited Case Manager (ACM) certification
Top 5 Reasons to Live in Carson City, Nevada
- Live, work and play in one of the most beautiful regions in the world
- Enjoy an array of outdoor activities world class skiing, golf, camping, mountain biking, hiking, water skiing, kayaking, hunting and fishing
- Just next door is Beautiful Lake Tahoe
- We are minutes from Reno known as the 'biggest little city in the world' - Fine dining, nightlife, shopping and home to the University of Nevada Reno.
- Family friendly atmosphere with affordable housing & excellent school system
Our Benefits
- No State Income Tax
- Medical, Dental, Vision, FSA, Telehealth
- Paid Time Off, Mental Health, and Volunteer Days
- 100% Vested 401K & Roth with Company Contribution
- Tuition Reimbursement
- Referral Bonuses
- On Site Education & Certification Programs
- Base Wage Increases for Relevant Advanced Degrees
- Free Calm App Subscription