Description

US:NV:Carson City Integrated Care Management

Full Time Day Shift

About Carson Tahoe Health

CTH is a not-for-profit healthcare system with 240 licensed acute care beds, fully accredited by the Center for Improvement in Healthcare Quality (CIHQ). CTH was voted 5 th most beautiful hospital in the nation nestled among the foothills of the Sierra Nevada in North Carson City and only a short drive away from world-famous Lake Tahoe & Reno. We serve a population of over 250,000 and feature two hospitals, two urgent cares, an emergent care center, outpatient services and a provider network with 19 regional locations.

Summary

• This individual is responsible to facilitate care through the continuum utilizing effective resource coordination to promote optimal access to care balancing the patients' resources and right to self-determination
• The overall responsibility to assess the patient for transition of care needs and risk for readmission
• This individual will be able to conduct complex psycho-social assessments and provide interventions to assist with throughput, safe discharges and avoid readmissions

Responsibilities

Transition Management

• Completes initial /comprehensive assessment within 24 hours of admission, including anticipated transition (discharge) plan
• Provides psycho-social assessment and intervention for patients identified with behavioral health issues, lack of social support systems, financial barriers, end of life and plan of care adherence
• Ensures plan of care and interventions are implemented and communicated to health care team, patient/family and post-acute care providers
• Complete timely, accurate and concise documentation in the EMR Care Coordination
• Screens high risk and referred patients for psycho-social issues/barriers, that may impact the transition plan and intervenes as appropriate
• Assists with adoption/abuse/neglect cases and reports to appropriate external agencies as required
• Collaborates with patient/family/health care team to ensure patient preferences and choices are taken into consideration within the limitations of available resources Education
• Ensure patient/ family receive education appropriate to their specific discharge plan
• Provides education to medical and nursing staff regarding relevant issues related to transition plan Compliance
• Ensures compliance with local, state and federal regulations and accreditation requirements
• Operates within social work scope of practice as defined by the state licensing board Complex Case Management
• Completes clear, concise and accurate initial/discharge planning/complex psycho-social assessments and reassessments per departmental guidelines (assessments within 24 hours of admission, reassessments every 3 days or as needed for change)
• Escalates barriers to transition planning per departmental escalation plan
• Completes post-acute referrals within 3 days of admission
• Schedules and facilitates complex case patient/family conferences as needed (at a minimum of weekly)

Qualifications

Required:

• Bachelor in Social Work from accredited school of Social Work
• Excellent interpersonal, written and verbal communication skills
• Demonstrated organizational skills, critical thinking and problem solving skills and computer literacy
• Unrestricted Social Worker license (LSW) in the State of Nevada

Preferred:

• Master in Social Work from accredited school of Social Work
• Two (2) years of acute care coordination experience
• Ability to obtain Accredited Case Manager (ACM) certification

Top 5 Reasons to Live in Carson City, Nevada

• Live, work and play in one of the most beautiful regions in the world
• Enjoy an array of outdoor activities world class skiing, golf, camping, mountain biking, hiking, water skiing, kayaking, hunting and fishing
• Just next door is Beautiful Lake Tahoe
• We are minutes from Reno known as the 'biggest little city in the world' - Fine dining, nightlife, shopping and home to the University of Nevada Reno.
• Family friendly atmosphere with affordable housing & excellent school system

Our Benefits

• No State Income Tax
• Medical, Dental, Vision, FSA, Telehealth
• Paid Time Off, Mental Health, and Volunteer Days
• 100% Vested 401K & Roth with Company Contribution
• Tuition Reimbursement
• Referral Bonuses
• On Site Education & Certification Programs
• Base Wage Increases for Relevant Advanced Degrees
• Free Calm App Subscription