Employment

Primary Function

• The Licensed Clinical Social Worker is a licensed professional. The incumbent provides a wide range of social work and care management activities to eligible Primary Care patients. The incumbent carries clinical responsibility for Primary Care and acts as liaison with social work programs including state, BIA, community and tribal social work activities. The incumbent is the official liaison between Primary Care and other social service and human service programs in the area, including Tribal, BIA, community, courts, and other medical facilities upon request for the Indian population served.

  Job Duties

• Plans and provides direct social work services to Primary Care patients and their families on an individual or group basis. Services may include but are not limited to assisting patients and families cope socially and emotionally with physical disability and/or illness, discharge planning, arranging patient transfer and transporting to other facilities, financial planning, and death and dying counseling, advanced directive counseling, referral to other resources, counseling services, and child abuse/neglect referrals. Provides needed services as determined from a developed plan of care and assessment.
• Through consultation, shares social evaluations and knowledge of patients, their families, and community resources with physicians, planning for the treatment and/or rehabilitation of patients. Establishes and maintains liaison and close working relationships with county social services, related agencies and organizations in the service unit to secure services for American Indians on the same basis as for non-Indians. Attends conferences and meetings relating to social service practices.
• Develops an individual primary plan of care, assesses patients' needs through interviews with patients, relatives, and others to obtain pertinent information.
• Responsible for establishing, implementing, and enforcing Social Services program policies and procedures and reviewing and revising existing policies and procedures at appropriate intervals.
• Insures conformance to acceptable standards of Social Service and Case Management practice, including all policies, procedures, rules, and regulations of the Cherokee Indian Hospital, JCAHO, CMS, and State Division of Medical Assistance.

• Utilizes the care management platform for documentation of care management functions such as a care needs screening, Comprehensive assessment, and care planning. Also utilizes the dashboards, within the care management platform for population health and related interventions and innovations
• Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care
• Participates in the continued development of the role of Case Management in the Patient Centered Medical Home (PCMH) and Advanced Medical Home (AMH and AMH+)and EBCI Tribal Option.
• Provides Care management for patients throughout the age continuum.
  • Develops implements and evaluates care plans, based on screenings and assessments.
  • Promotes health care outcomes with currently accepted clinical practice guidelines.
  • Provides patient education, advice and information on health assessment, treatment plans and available community resources.
  • Assesses patient needs using established clinical guidelines, protocols, and pathways.
  • Provides appropriate follow up as directed or per established guidelines.
• Performs ongoing assessment by actively participating in the determination of meeting the care needs or gaps in care based upon collection and interpretation of data relevant to the health status of the client.
• Performs ongoing assessment by actively participating in the determination of meeting the nursing care needs based upon collection and interpretation of data relevant to the health status of the client.
• Collects data from relevant sources (patient, family, or care giver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual and utilizes this data in patient center care plan development.
• Develops individualized plan of care with input from the patient, patient's family, pod members, and anyone else the patient requests to be included for those patients considered "high risk."
• Initiates individualized care plan based on assessment of the patient for specific illnesses, injuries, and diseases Social Determinants of Health (SDoH) and human behavior while adhering to appropriate standards of care.
• Develops expected patient outcomes that are observable and within an adequate time frame, and are congruent with the patient's present and potential physical capabilities and behavioral patterns.
• Responsible for planning, developing, and implementing the Social Service program. Directs Social Service activities within the organization including concurrent and retrospective reviews, identification of actual and/or potential delays in service and/or treatment, and reporting trends of inappropriate utilization of resources.

2

• Attends daily multidisciplinary inpatient rounds, confers with Inpatient Social Worker and Medical staff on Social Services and Case Management problems, develops, and implements plans for corrective action.
• Will assist nursing staff as needed with coordination of care and disposition of patients from the Primary Care, such as, but not limited to patients requiring placement or transfer to mental health facilities and other facilities.
• Interprets patient's resource and case management needs to the Medical and Nursing staff and collaborates with them in the determining available resources. Maintains communication with insurance providers in determining plan of care and coordinates care with the patients' Integrated Care Team.
• Reviews Purchased and Referred Care referrals daily through the RPMS and maintains liaison with the referral organization to determine plan of care, anticipated discharge or transfer dates, and case management needs under the direction of the Primary Care DON/Assistant Director of Care Management.
• Responsible for identifying providers or services needed to coordinate the patient's care in the Primary Care setting, or upon discharge from the Cherokee Indian Hospital or regional facility.
• Maintains files and prepares reports on Social Service and Case Management activities and areas for improvement for submission to the Primary Care DON/Assistant Director Care Management and other appropriate groups.
• Maintains and promotes positive and constructive communications and activities within nursing services, other departments, tribal, and community agencies for purposes of coordinating and understanding of program goals.
• Participates in the development and implementation of Performance Improvement activities and participates or leads at least one Quality Improvement activity per year (PDSA).
• Attends meetings, planning sessions, committees, and serves on teams to promote quality and performance improvement.
• Actively participates with the Integrated Care teams in planning, organizing, and directing departmental services.
• Participates in various hospital committees as assigned.
• Performs other related duties as required.

  Job Knowledge

• Knowledge of principles, practices, techniques, and theories of social work in order to plan and provide social services to meet the physical, emotional, spiritual, and socio cultural needs of patients of all ages; specifically, Infancy (Birth-1 year), Toddler and Early Childhood (2-5 years), Latency (6-9 years), Preadolescence (10-12 years), Early Adolescence (13-15 years), Adolescence (16-20), Adult (21-64 years), and Elderly (65­+ years).
• Knowledge of social services and its application to clinical practice.
• Knowledge of disease process, health care treatment and systems, and treatment protocols.
• Knowledge of health care financial management, provider payer mechanisms, business environment, and resource management.

3

• Knowledge of strategic planning, outcome measurement, quantitative methods and statistics.
• Knowledge of ICD_1 0, coding, billing practices.
• Knowledge and ability to analyze the results of various medical procedures and translate into appropriate plans of care.
• Knowledge of nursing home admission requirements, including steps to initiate nursing home processing.
• Knowledge of Family Care Services policy and procedures and ability to coordinate care requirements with patient centered goals in mind.
• Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations.
• Knowledge of the occupational functions of multi-disciplinary integrated health care teams.
• Knowledge of the culture and health profile of the patient population.
• Knowledge and ability to teach and counsel patient/family and staff on plans for care and use of health care resources.
• Knowledge of available health care programs and community resources.
• Knowledge of processes and procedures for establishing, revising, continually monitoring, and evaluating standards for Social Services.
• Knowledge of medical record documentation and how to perform medical record reviews.
• Ability to communicate to and interact with persons, (staff, health care professionals, individuals in the community) with different functions, levels of knowledge, and requirements.
• Knowledge of JCAHO accreditation standards, social services quality improvement standards, HCFA regulations, Medicare, Medicaid, and private insurance.
• Knowledge of clinical teaching methodologies and methods of evaluating the effectiveness of teaching strategies.
• Ability to gather and analyze data and communicate findings.

  Complexity of Duties

  Guidelines consist of professional standards of practice, medical policies and procedures. Must comply with Compliance Plan, Utilization Review Plan, State and Federal guidelines, CMS, FPM, DHHS, PHS, and IHS regulations. These guidelines are not always specifically applicable to the individual patient or situation and independent judgment is required in selecting the most appropriate guideline, and applying the intent. Requirements are complex in that they require comprehensive skills in Social Services and Case Management and have sufficient knowledge of medicine to evaluate patient care. This may involve difficult interactions with the clinical staff, case managers, care managers and insurance payers and require maximum skills in diplomacy and judgement.

  Education/Experience

• Master's Degree in Social Work required.
• Licensed in the state of NC as a LCSW.
• At least 2 years' experience as a Social Worker. Prefer that experience reflect knowledge of Hospital Social Work.

4