Nemours is seeking a Care Management Social Worker to join our team in Wilmington, DE! The Care Management Social Worker (CM SW) will assist patients and families in identifying social, emotional and environmental needs that may impact the ability to maintain healthy behaviors and disease management. The CM SW will assist in connecting patients and families with available, appropriate resources and services through the provision of a full spectrum of transition planning and social work services. The CM SW will identify and monitor pediatric patient needs in collaboration with the clinical team around care coordination. She/he will collaborate with the patient/family, physicians, staff and other health care professionals across the continuum to provide care coordination and patient services to achieve positive clinical, operational and financial outcomes. This position is embedded at the Alfred I duPont Hospital for Children, with occasional need to travel.

QUALIFICATIONS

• Case Management certification within 2 years of hire
• Licensed Clinical Social Worker unrestricted in the State of Delaware and Pennsylvania
• Bilingual (English/Spanish) speaking strongly preferred

PRIMARY RESPONSIBILITIES

• Perform ongoing telephonic case management activities of assessment, problem identification, planning, implementation, coordination, monitoring, and evaluation of case managed pediatric patients and their families. Stratifies and/or validates patient level of risk during each transition process and interaction with the patient and family
• Identifies problems or gaps in community resources that impact outcomes and takes leadership in efforts to effect changes. Coaches patients and their families on red flags, triggers, medication management, and follow-up appointments
• Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources to support care plan development
• Provides psychosocial support through individual and/or family counseling. Continuously reviews service area for group/family support needs and opportunities and refers to appropriate resources
• Manages assigned case load in an efficient and effective manner utilizing time management skills to facilitate the total work process directly monitoring assigned patients or beneficiaries
• Confers with Medical Director regarding complex cases requiring physician input regarding the treatment plan or physician to treating physician collaboration
• Identifies system issues that serve as barriers to care. Participates in development and implementation of strategies to remove barriers and promote resolution through coordination of a problem solving process
• Collaborate with embedded inpatient case managers and care coordinators in the discharge and transitional care process, obtaining and/or coordinating appropriate resources for patients throughout the continuum of care. Makes appropriate referrals to Pharmacist and Disease Management programs as needed
• Performs assigned work safely, adhering to established departmental safety rules and practices. Reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.