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Decypher is seeking a Licensed Clinical Social Worker to support the contract at David Grant Medical Center, Travis AFB, CA.
Assessment: Proactively identifies and evaluates patients and families for case management from various sources such as discharge/disposition planning, referrals, the Medical Evaluation Board (MEB) process, the healthcare system, employers, and facility staff. Conducts systematic, ongoing, thorough collection of patient's physical, emotional, psychological, social, and medical status and information, including direct patient contact and other relevant sources such as professional and non-professional caregivers, medical records, and family/caregiver interviews.
Planning: Develops an appropriate patient-specific plan of care to include short and long-term goals, objectives, and actions. Coordinates, collaborates, and obtains approval of the plan among the patient, family/caregiver, primary provider, and other members of the healthcare team.
Implementation: Guides the patient and family/caregiver through the healthcare system, maximizing use of resources. Coordinates and executes the plan of care, optimizing access to appropriate services. Ensures necessary referrals are ordered by the appropriate discipline and coordinated. Serves as an advocate for, and ensures education is provided to, the patient and family/caregiver as required. Promotes adherence to treatment plans for improved healthcare outcomes.
Coordination: Ensures coordination of care delivery processes, including alternate healthcare settings and the home environment, to enhance the patient's health and wellness, safety, productivity, and quality of life, and to provide the most beneficial, cost-effective healthcare. Develops, utilizes, and maintains a variety of military and community resources to optimize access to services and medical care. Ensures timely and appropriate provision of services.
Monitoring: Documents and updates the treatment plan as needed in accordance with existing DoD, AF, local facility, and other agency guidelines. Maintains documentation and data collection in accordance with DoD, AF, local facility, and other specified agency guidelines. Conducts and/or participates in program evaluation as directed.
Evaluation: Monitoring and evaluation may include, but are not limited to: patient's adherence and response to the treatment plan; timeliness of patient and family/caregiver contact and follow-up; identification of variances, patterns or trends from established practice guidelines and/or standards; established outcome measurements; results of interventions, treatment delivery, and timeliness of care; and utilization of resources. Monitors and evaluates the facility's case management program per DoD, AF, and local policies and guidelines.
Interdisciplinary Coordination: Coordinates and participates in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings. Shares knowledge and experiences gained from own clinical practice and education relevant to the field of social work and case management. Participates in the orientation and training of other staff. May serve on committees, work groups, and task forces at the facility.
Compliance: Must maintain a level of productivity and quality consistent with the complexity of the assignment; facility policies and guidelines; established principles, ethics, and standards of practice of professional nursing; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); CAMH; (AAAHC); Health Services Inspection (HSI); and other applicable DoD and Service-specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control, and safety policies and procedures.
Documentation: Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies, and guidance.
Training: Completes all required electronic medical record training, MTF-specific orientation and training programs, and AF/DoD mandated Case Management training.
Telework: Possible to telework at the Flt/CC discretion.
Degree/Education: Master's degree in Social Work (MSW). Graduate from a School of Social Work fully accredited by the Council on Social Work Education (CSWE).
Certifications: In addition to Basic Life Support: Certified Case Manager by Commission for Case Management (CCM) or National Association of Social Workers (NASW) -OR- certification eligible with 2 years full-time experience in case management for adults, children, families, seniors, and groups.
Experience: As required to meet clinical competency requirements specified in the Service-specific credentialing instructions. Must have the knowledge to effectively apply core case management functions: a) Assessment: identification of patients for case management; comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care; b) Planning: Collaboration with the patient, family/caregiver, primary provider, and other members of the healthcare team for developing an effective plan of care; c) Facilitation: Care coordination and communication among all involved parties; and d) Advocacy: Support for the patient and family/caregivers to ensure identified education and appropriate, timely care is received. Must be knowledgeable in theories, principles, and methodologies underlying psychosocial practice; developmental growth; dynamics of human behavior, family, and other social systems; and the impact of illness and disability on social functioning; medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]) and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC); and computer applications/software including Microsoft Office programs, MS Outlook (email), and internet familiarity is required. Minimum of 2 years full-time experience in professional case management or discharge planning programs for adults, children, families, seniors, and groups. Must be skilled in program planning, implementation, and evaluation, and in conducting individual, family, group, and community assessments; applying critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations; and problem-solving to articulate medical requirements to patients, families/caregivers, medical and non-medical staff in a professional and courteous way.
Licensure: Current, full, active, and unrestricted license to practice as a Licensed Clinical Social Worker. A current valid license having no adverse action pending from any state or national licensing/certification agency. A Social Worker license is defined as a license that allows the Social Worker to work independently without clinical supervision.
