Continuing Care Manager - Social Worker - Dartmouth-Hitchcock Health
Lebanon, NH
About the Job
Overview:
Facilitates the management of illness, with the focus on Neurologic Oncology patients, striving to achieve measured advancements in the patient's health status.
Responsibilities:- Manages and coordinates interdisciplinary care of defined populations through the care continuum from wellness through end of life from a psychological, social and environmental perspective.
- Identifies high risk patients requiring on-going coordination of care; performs a comprehensive patient/family assessment, develops a comprehensive treatment plan that will span the continuum of psychosocial issues, implements a plan of care to provide continuing support and coordination for patient/family with multiple complex system needs, manages benefits and negotiates continuing care services for enrollees in various health insurance plans, etc.
- Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in regards to psychological, social and environmental areas.
- Monitors the patient’s transition across and within care settings (e.g., home, clinic, skilled nursing facility, rehabilitation, hospital, etc.).
- Shares assessment and psychological, social and environmental care plan data with patient/family consent as the patient moves through different care settings.
- Identifies gaps in the care continuum and work with the community and provider networks to expand access to needed psychological, social and environmental services.
- Participates in the development of disease management strategies and identifies the appropriate measures for the evaluation of outcomes.
- Participates in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization.
- Collects and evaluates data/outcomes, including, but not limited to, patient satisfaction, health and functional status, and resource utilization.
- Performs other duties as required or assigned.
- Collaborative team player, use of systems approach in planning, problem solving and decision making, creativity, innovation, risk taking, autonomy, flexibility, receptiveness to change and a commitment to professional growth desired.
- Understanding of and comfort using computers desired.
- Critical thinking skills, strong leadership and communication abilities, the ability to be a self-starter, negotiate, and handle conflict resolution desired.
- Master’s Degree in Social Work (MSW) with 5 years of clinical experience required.
- None
Source : Dartmouth-Hitchcock Health