Job Description
Job Description
- Candidates will also be required to travel to surrounding counties to see clients.
Visiting Nurse Health System is the largest non-profit Home Health & Hospice Agency in the State of Georgia!
Celebrating 75 years of active service, our mission is to improve the lives of those we serve.
If you’re one of those people who won’t settle for ordinary and want to be extraordinary by touching the lives of others, Visiting Nurse | Hospice Atlanta may be the ideal career choice for you.
As the leading provider of home health and hospice care in Atlanta, we offer a great variety of highly rewarding job opportunities for unique individuals just like you. We understand that you want to truly make a difference in the lives of patients and their families.
As a member of our team, you can utilize your skills, share your compassion and rare talents to provide a full continuum of care in the comfort of a patient’s home. In addition, you can apply your gifts by providing aging services and hospice care to adults and children.
Benefits :
Medical InsuranceVision InsuranceDental InsuranceLong-Term & Short-Term Disability403B Retirement Benefits6 Paid HolidaysMileage ReimbursementAnd more!About the Position :
The Care Manager – Social Worker for the Source Program resides in VNHS' Community Care Department, providing enhanced care management activities necessary to meet the needs of members assigned to the multi-team. This position is responsible for the development and implementation of individualized care paths through brokering and coordinating services; and the monitoring and evaluation of all clinical outcomes to ensure that services are provided in a professional, comprehensive, and cost-effective manner.
MINIMUM JOB REQUIREMENTS
Education & Qualifications :
Education & Experience : Master’s or bachelor's degree in social work, Sociology, Psychology, or a related field plus a minimum of 2 years’ experience in case management in a health care field. Preference given to national certification in case management. Current CPR certification required.Knowledge / Training : Knowledge of Medicare, Medicaid and other funding source regulations as applied to service program. Demonstrates knowledge and competence in advanced practice nursing skills, including the nursing process, and collaborating with interdisciplinary teamSkills : Must be able to function independently and efficiently in community-based environment. Requires proven interpersonal skills with an ability to communicate effectively. Demonstrates proven decision skills, organizational, self-discipline, and time management skills. Must be skilled in physical assessment and development of care plans.Computer Skills : Must be proficient in MS Office and have the ability to self-manage online HR services and online training programs.Transportation : Must have reliable transportation.JOB SPECIFIC EXPECTATIONS
Coordination of Services
Maintains current knowledge of and arranges both SOURCE and non-SOURCE community-based services in collaboration with the Nurse Care Manager, the Member / caregiver.Ensures emergency preparedness plans are in place for all Members; demonstrates knowledge of and ability to implement emergency plans with Triage Level 3 and 4 Members according to VNHS policyServes as the transition point and link between the assessment process and the effective delivery of direct servicesSeeks consultation with nurse regarding Member medical issues to ensure on-going continuity of careAttends weekly multi-Team meetings with Medical Director & nursing staff to establish Carepath goals & evaluate any changes in Member condition.Monitors service delivery to each Member; follows-up on each service to determine if the service is appropriate and if it is effectively meeting the Member’s needsAssessment and Carepath
Develops appropriate Carepath specific to each Member’s condition and needs in consultation with the Member, Member’s caregiver, Nurse Care Manager, and service providersReviews Member version with Member and has Member or caregiver sign and date signature page at each quarterly reviewActivates the Carepath and facilitates brokering of SOURCE servicesIdentifies changes in Member condition / needs and adjusts the Carepath accordingly at every Carepath review Completes GDS, MMSE, falls assessment, and other advanced assessments as indicated including documentation and follow-up as determined by the advanced assessment scoreDemonstrates an understanding of the causes and interventions related to falls and other critical incidents if deemed appropriate.Works with Members and caregivers to develop specific, realistic discharge plans, and documents plans in Member’s file.Accompanies Nurse during initial assessment or reassessment when required by nurse or management team.Documentation
Documents all care management activity and service-related information, as required by DCH & VNHS policy or as directed by management, on a daily basisUses list of approved abbreviations in documentationEnsures that documentation is consistent with the format required by both DCH & VNHS standards (i.e., progress notes reflect Carepath)Maintains confidential case records on all SOURCE Members according to VNHS HIPAA Standards & DCH StandardsDemonstrates the ability to follow through in a thorough and timely manner on tasks assigned by management team and requests made by Members / caregivers, referral sources, and othersDocuments appropriate follow up and / or resolution on Member needs whether related to SOURCE services or other community resource needsDocuments SW initial 10-day call note that includes introduction to SOURCE program.Documents in a professional, nonjudgmental, and grammatically correct format with minimal typographical errorsFinancial
Approves type and frequency of services appropriate to the Member’s needs while assuring that costs do not exceed the limitations established by the Division of Aging Services and the Department of Community Health.Assures payment of service providers within the DCH standards of promptness following the initiated service dateEnsures services are provided at a level that is clinically appropriate and based on Member’s condition and needsGeneral Duties
Maintains current knowledge about the eligibility and ordering standards for each SOURCE serviceMaintains understanding of specialized programs in which SOURCE participates, such as the Consumer Directed Option & Person-Centered Care.Participates actively in weekly multi-Team conferences to coordinate care, problem-solve, and exchange views and information; documents case conference activities and follow upAttends clinical supervision at least monthly and when appropriate presents difficult cases as indicatedAttends quarterly network meetingsChecks voicemail two times per day and email daily, at minimumServes as in office triage worker according to the rotation scheduleSets own schedule in a manner that accommodates timely Member visits as well as allows for a minimum of two days per week in the officeMaintains a working knowledge of Medicaid & Medicare services to effectively coordinate services and identify benefit coordination for MembersRegulatory
Demonstrates knowledge and understanding of SOURCE care coordination and provider manualsDemonstrates knowledge of and adheres to the policies and procedures of Visiting Nurse Health SystemComplies with standards of promptness set forth by DCH and VNHS policy regarding specific activities : o Follows up on services ordered and any changes within 10 business daysPerforms face-to-face Carepath reviews within 90 days of the initial brokering date o Performs monthly contact phone calls
Performs face-to-face quarterly Carepath reviews every 3 months at a minimum or more often as needed o Signs and returns MIFs to providers within 3 days of being received at SOURCECompletes PCP Conference sheets quarterlyInfection Control
Demonstrates knowledge of infection control standards and required practices as per VNHS policy and procedures and consistently practices these techniques
