Arbor Health, an equal-opportunity employer, offers competitive compensation and excellent benefits for our employees.
Arbor Health is committed to providing a drug-free work environment. Pre-employment substance abuse screening is required as a condition of employment.
Information regarding the Family and Medical Leave Act (FMLA) can be found here.
Email completed application to firstname.lastname@example.org or email@example.com
Responsible for identifying and interacting with medically and psychosocially complex patients and families who are likely to benefit from care management and meet high-risk criteria and for coordination of discharge planning services for these patients in collaboration with RN Care Management and other members of the care team. Indirect services include the development and ongoing implementation of standardized clinical tools including the identification and use of Mental Status Exams, risk assessments, planning and coordination with the assigned Behavioral Health Agency. Responsible for clinical review to ensure quality control and agency standards. Direct services include assessment for persons experiencing acute/urgent emotional or mental problems.
Primary Job Responsibilities:
- Screen and identify patients who need care management per high-risk criteria.
- Assess, develop, implement and monitor a comprehensive discharge plan of care through an interdisciplinary team process in conjunction with the patient and family. Collaborate with the multi-disciplinary team to identify problems or needs that require special planning, intervention, teaching or follow-up.
- Identify key problems, strengths, and resources to be addressed in the discharge plan of care. Coordinate and facilitate improved ability to comply with the plan of treatment; counseling or support needed to cope with a situation; improved ability to access appropriate level of care due to lack of financial resources or lack of available service.
- Actively support measures that promote effective use of resources.
- Identify, plan and arrange for appropriate services applying knowledge of services available in the community, state, and federal health regulations and admission, discharge and appropriate level of care. Coordinate effective planning and arranging for needed services upon discharge.
- Intervene by arranging services, education and providing psychosocial support to prepare the patient and their family to manage their healthcare needs within the acute care setting and post-discharge.
- Coordinate with the interdisciplinary team and community resources when appropriate, regarding the multiple details of transitional care management plan. Consult with the physician as indicated.
- Works with patients identified and referred to them by RN Care Management and/or other members of the care team, as well as by patients/families.
- Conducts evaluation to include appropriate documentation and the effectiveness of the Care Management services. Collaborates with team members to identify the cause and adjust the plan if the patient’s health status is not improving.
- May counsel patients and/or families to facilitate and/or participate in community care services, in coordination with the physician and treatment team. Works as an integral member of the treatment team in the coordination of treatment and transition of care planning. Assesses and addresses both mental health and chemical dependency conditions. May perform risk assessments for suicidality and homicidality.
- Performs other duties as assigned. Minimum Qualifications
- Master’s Degree in counseling, social services or closely related field, holding a professional license, (LMHC/A, LMFT/A, or LICSW/A) able to obtain full licensure within one year of hire. (necessary in order to bill for services after 2020 when the grant runs out
- Proficient in computer use and applications commonly used or applied in this field/trade/position for the development of reports, documents, presentations and access/utilize databases for care management and Microsoft Office software.
- Possess and maintain a valid driver’s license. Pass and maintain a clear background record as required for healthcare organization under state and federal contracts. Preferred Qualifications
- Professional licensure as an LMHC, LMFT, or LICSW.
- Minimum of two years employment in a healthcare setting or community agency dealing with health and/or welfare issues preferred.
- Certification in Case Management highly preferred.
- Current Healthcare Provider CPR certification, American Heart Association BLS, or obtain within first 6 months of employment.
Required Skills and Abilities:
- Knowledge of applicable contracts, standards, laws, rules, and regulations (such as HIPAA, WAC, RCW, CFR).
- Knowledge of Clinical practice; especially in the areas of care coordination, recovery and consumer-driven treatment plans, cultural competence, and evidenced-based practices.
- Leadership skills to enforce compliance obligations, assist with policy training and support, and implement corrective actions.
- Effectively work in a collaborative team and diverse environment. Coordinate and organize groups and meetings to accomplish goals and tasks.
- Effectively work in a multi-task environment, prioritizing tasks properly, completing tasks/projects in a timely manner and meet multiple deadlines.
- Develop and maintain effective working relations with peers, participants, other agencies, contracted providers, and the public.
- Work well independently, learn quickly and adjust work assignments in response to system changes.
- Exercise good judgment and maintain confidentiality and handle sensitive information with discretion.
- Proficient in the development of professional oral and written communications. Prepare effective reports and presentations to diverse audiences, such as the public and participants, elected officials, government and non-profit entities, special interest/community groups, and peers. Skilled in persuasive and motivational communications.
- Ability to make effective recommendations for plans of action, and assist in implementing them. Resourceful in finding effective solutions or alternatives. Analyze issues, understand and apply contractual obligations and legal mandates, summarize findings, and articulate and execute action steps.
- All positions at Arbor Health require the protection of the privacy and security of personal health information as defined in state and federal law.
- Be cognizant of the diverse nature of the populations we serve and the participants we work with, and reflect inclusiveness in our behavior, communications, and in the programs and processes we develop.
- Excellent verbal and written communication skills including sensitivity to other cultures and ethnicities.
- Excellent skills in conceptual thinking, listening, problem resolution and planning.
- Demonstrated leadership skills.
- Excellent organizational skills.
- Proficient computer skills including MS Office applications and electronic medical records.
- Knowledgeable about issues related to chronic illness, developmental disabilities, special needs, mental illness, grief and transition, substance abuse, domestic violence, child abuse, and senior abuse.
- Good understanding and adherence to core social work values and ethics.
Standard for portrayal of mission and values:
- Employee demonstrates and fosters the Lewis County Hospital District No. 1 values of achievement, creativity and innovation, teamwork, quality, and integrity.
- Employee demonstrates and fosters the mission of Lewis County Hospital District No. 1 to provide our highest level of compassionate, diligent and professional medical care.
- Is cooperative and supportive to others within the department and hospital providing care and services.
- Treats individuals including patients, co-workers, supervisors, management, patient families, physicians, volunteers, visitors, and others with respect, dignity, and fairness.
- Behaves professionally and ethically in all interactions with patients, co-workers, supervisors, management, patients' families, physicians volunteers, and others.
- Is consistently courteous to patients, co-workers, supervisors, management, patient’s families, physicians, volunteers, and others; greets individuals and provides assistance and direction in an attentive and helpful manner.
- Willingly strives at continuous quality improvement to achieve quality work the first time every time.
- Is willing to learn new procedures and develop new skills for the purpose of improving quality of care and services.
- Willingly participates as a member of the work team(s) supporting the goals and objectives of the department and the district.
- When answering the telephone, is courteous to the caller, clearly identifies department, name and takes a message or directs calls as necessary in a helpful manner.
Open until filled