Department: Care Management Services FTE: 1.00 Full Time Shift: Days
Position Summary: Manage the medically related social and emotional needs of patients and their families as needs impinge on patient medical conditions, treatment, recovery and safe transition from one level of care to another. Coordinate care with physicians, nursing staff, case managers and allied health professionals ensuring that patient outcomes are achieved within established timeframes and with maximum efficiency in resource utilization. Conduct high-risk screening, initial and ongoing psychosocial assessments. Ensure continuity of care through case management and discharge planning, providing social work interventions to expedite timely discharges, monitoring patient outcomes, and analyzing variances. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include Neonate, Pediatric, Adolescent, Adult and Geriatric age groups.
Detailed responsibilities: * PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable * IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral * CASE MANAGEMENT - Provide case management and discharge planning services in a timely and cost-effective manner to include patient assessment, planning, implementation, coordination, monitoring and evaluation * ASSESSMENT - Complete psychosocial assessment of identified patients whose medical status, recovery, or timely discharge may be impeded by inadequate social, environmental, or economic conditions, by inadequate funding sources, and/or by impaired emotional or cognitive status including decisional incapacity * ASSESSMENT - Assess patient level of functioning, including developmental, physical, environmental, cognitive, behavioral, psychological, economic, social, cultural and spiritual factors * PATIENT ASSISTANCE - Provide assistance to facilitate patient recovery, discharge and/or management of an acute, chronic or terminal illness or condition; assistance may include education, community referrals, advocacy, and mediation with patients and families to assist in adjustment to changes in health status and functioning expediting timely discharge to an appropriate level of care * OUTCOMES - Identify patients with a history of medical non-compliance, high resource utilization and poor outcomes; monitor patient outcomes, re-evaluate plans of care to accommodate changes in treatment or progress * GOALS & OBJECTIVES - Assist in resolution of identified barriers and develop alternative goals and objectives with patients and family members * DOCUMENTATION - Document assessment data, patient problems, interventions taken to achieve outcomes and evaluation of patient progress toward targeted outcomes * LIAISON - Serve as UNMHSC liaison to state protection agencies for all reports and/or concerns of patient abuse, neglect or exploitation * LEGAL COORDINATION - Coordinate with UNMHSC Office of Legal Counsel regarding matters involving treatment guardianship and/or other legal issues * COMMUNICATION - Use effective communication strategies with patients, families, physicians, nurses, allied professionals and others to achieve desired patient outcomes and patient satisfaction * CARE COORDINATION - Coordinate multidisciplinary care planning, including patient care conferences as appropriate to facilitate resolution of treatment decisions and timely discharge planning * RELATIONS - Develop and maintain positive relationships with community agencies and third party payor sources * EDUCATION - Contribute to education of physicians, nurses, allied health professionals and students * RESOURCE - Acts as resource to professional colleagues; provide staff training, development and consultation as appropriate * DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops * PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols * PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes * PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk * PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner * PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right" * LIVING DONOR ADVOCATE - Assist the living donor in obtaining and understanding information regarding the following: evaluation and consent process, surgical procedure, risk and benefit of donation, financial aspects of living donation, options available to the recipient other than live donor kidney transplantation, short and long term consequences of kidney donation and the need for long term follow up post donation * LIVING DONOR ADVOCATE - Promote, protect, represent, and advocate for the rights of potential living kidney donors throughout all phases of the transplant process * LIVING DONOR ADVOCATE - Respect donor's decision and ensure that decision is voluntary, informed and free of coercion * LIVING DONOR ADVOCATE - Maintain confidentiality and ensure donor has an understanding of the "Opt-Out" process
Experience: Essential: No minimum experience required
Nonessential: Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo
Credentials: Essential: * NM LMSW or LPC or LCSW * CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days Nonessential: * Licensed Clinical Social Worker in New Mexico * Licensed Master's Social Worker in New Mexico
Physical Conditions: Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Working conditions: Essential: * No or min hazard, physical risk, office environment * May be required to travel to various work sites * May be required or is required to perform on-call duties * May work rotating shifts, holidays and weekends
What Information Do We Collect?
When you visit our website you may provide us with two types of information: personal information you knowingly choose to disclose that is collected on an individual basis and website use information collected on an aggregate basis as you and others browse our website.
Personal Information You Choose to Provide
We may request that you voluntarily supply us with personal information, including your email address, postal address, home or work telephone number and other personal information for such purposes as correspondence, placing an order, requesting an estimate, or participating in online surveys.
If you choose to correspond with us through email, we may retain the content of your email messages together with your email address and our responses. We provide the same protections for these electronic communications that we employ in the maintenance of information received by mail and telephone.
Website Use Information
Similar to other websites, our site may utilize a standard technology called "cookies" (see explanation below, "What Are Cookies?") and web server logs to collect information about how our website is used. Information gathered through cookies and server logs may include the date and time of visits, the pages viewed, time spent at our website, and the sites visited just before and just after ours. This information is collected on an aggregate basis. None of this information is associated with you as an individual.
How Do We Use the Information That You Provide to Us?
Broadly speaking, we use personal information for purposes of administering our business activities, providing service and support and making available other products and services to our customers and prospective customers. Occasionally, we may also use the information we collect to notify you about important changes to our website, new services and special offers we think you will find valuable. The lists used to send you product and service offers are developed and managed under our traditional standards designed to safeguard the security and privacy of all personal information provided by our users. You may at any time to notify us of your desire not to receive these offers.
What Are Cookies?
Cookies are a feature of web browser software that allows web servers to recognize the computer used to access a website. Cookies are small pieces of data that are stored by a user's web browser on the user's hard drive. Cookies can remember what information a user accesses on one web page to simplify subsequent interactions with that website by the same user or to use the information to streamline the user's transactions on related web pages. This makes it easier for a user to move from web page to web page and to complete commercial transactions over the Internet. Cookies should make your online experience easier and more personalized.
How Do We Use Information Collected From Cookies?
We use website browser software tools such as cookies and web server logs to gather information about our website users' browsing activities, in order to constantly improve our website and better serve our users. This information assists us to design and arrange our web pages in the most user-friendly manner and to continually improve our website to better meet the needs of our users and prospective users.
Cookies help us collect important business and technical statistics. The information in the cookies lets us trace the paths followed by users to our website as they move from one page to another. Web server logs allow us to count how many people visit our website and evaluate our website's visitor capacity. We do not use these technologies to capture your individual email address or any personally identifying information about you.
Notice of New Services and Changes
Occasionally, we may use the information we collect to notify you about important changes to our website, new services and special offers we think you will find valuable. As a user of our website, you will be given the opportunity to notify us of your desire not to receive these offers by clicking on a response box when you receive such an offer or by sending us an email request.
How Do We Secure Information Transmissions?
When you send confidential personal information to us on our website, a secure server software which we have licensed encrypts all information you input before it is sent to us. The information is scrambled en route and decoded once it reaches our website.
Other email that you may send to us may not be secure unless we advise you that security measures will be in place prior to your transmitting the information. For that reason, we ask that you do not send confidential information such as Social Security, credit card, or account numbers to us through an unsecured email.
How Do We Protect Your Information?
Information Security -- We utilize encryption/security software to safeguard the confidentiality of personal information we collect from unauthorized access or disclosure and accidental loss, alteration or destruction.
Evaluation of Information Protection Practices -- Periodically, our operations and business practices are reviewed for compliance with organization policies and procedures governing the security, confidentiality and quality of our information.
Employee Access, Training and Expectations -- Our organization values, ethical standards, policies and practices are committed to the protection of user information. In general, our business practices limit employee access to confidential information, and limit the use and disclosure of such information to authorized persons, processes and transactions.
How Can You Access and Correct Your Information?
You may request access to all your personally identifiable information that we collect online and maintain in our database by emailing us using the contact form provided to you within the site structure of our website.
Do We Disclose Information to Outside Parties?
What About Legally Compelled Disclosure of Information?
We may disclose information when legally compelled to do so, in other words, when we, in good faith, believe that the law requires it or for the protection of our legal rights.
Permission to Use of Materials
The right to download and store or output the materials in our website is granted for the user's personal use only, and materials may not be reproduced in any edited form. Any other reproduction, transmission, performance, display or editing of these materials by any means mechanical or electronic without our express written permission is strictly prohibited. Users wishing to obtain permission to reprint or reproduce any materials appearing on this site may contact us directly.
We are grateful for your donation and support of our organization. If you have made an error in making your donation or change your mind about contributing to our organization please contact us. Refunds are returned using the original method of payment. If you made your donation by credit card, your refund will be credited to that same credit card.
Automated Recurring Donation Cancellation
Ongoing support is important to enabling projects to continue their work, so we encourage donors to continue to contribute to projects over time. But if you must cancel your recurring donation, please notify us.