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Care Management-Social Worker

Job ID: 964484
Facility: ECU Health Phys Team Member
Dept: Heart Failure Greenvlle
Location: Greenville, NC
FT/PT: Full-Time
Shift: Not Applicable
Reg/Temp: Regular
Date Posted: Jul 7, 2023

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Job Description

ECU Health

About ECU Health

ECU Health is a mission-driven, 1,708-bed academic health care system serving more than 1.4 million people in 29 eastern North Carolina counties. The not-for-profit system is comprised of 13,000 team members, nine hospitals and a physician group that encompasses over 1,100 academic and community providers practicing in over 180 primary and specialty clinics located in more than 130 locations.

The flagship ECU Health Medical Center, a Level I Trauma Center, and ECU Health Maynard Children’s Hospital serve as the primary teaching hospitals for the Brody School of Medicine at East Carolina University. ECU Health and the Brody School of Medicine share a combined academic mission to improve the health and well-being of eastern North Carolina through patient care, education and research.

Position Summary

The Social Worker (SW) coordinates the delivery of care across the continuum and social work services to all inpatient and observation units of the hospital and designated outpatient and ambulatory treatment units. The SW provides collaboration and oversight in complex clinical issues to Nurse Care Managers (RN CM) and Discharge Coordinator (DC) staff. This role requires interaction with a variety of patient populations including, but not limited to, neonatal, pediatric, adolescent, adult, geriatric and behavioral health.

Provides advanced practice social work services related to patients' and family members' current and post-acute psychosocial and clinical needs. Completes psychosocial assessments; provides crisis intervention, emotional support, and short-term counseling with regard to diagnosis, treatment, and cross continuum care plans; and creatively identifies and accesses resources to optimize effective and efficient patient care outcomes in collaboration with other members of the - interdisciplinary team.

The SW is accountable for the management of identified complex care planning and social work functions for
assigned patient care area using advanced social work theory and advanced clinical practice skills appropriate to the age of the patient incorporating the patient/family's social and emotional state. Utilizes principles of individual, group and family therapy theories.

Proactive development, implementation and ongoing revision of an interdisciplinary plan of care. Negotiation and collaboration with the interdisciplinary team, community resources and payers to facilitate timely and cost effective care plans that enhance appropriate health and social services in the continuum of care are imperative.


1. Completes psychosocial assessments. Identifies, develops, and implements plan of care for patients whom advanced practice social work services would be beneficial. Completes and documents assessments using departmental procedures and within required time frames. Obtains information about patient's clinical status through collaboration with healthcare team and incorporates into assessment process. Identifies and applies information about patient's health behaviors, cultural influences, and belief or value system. Identifies, addresses, and re-assesses based upon potential barriers to plan and works with healthcare team to address.

2. Facilitates healthcare delivery process/coordinates care planning. Anticipates patients' and families' care needs, developing and implementing plans of care which enhance quality, access, and cost-effective outcomes, and identifying and addressing barriers to progression, in a timely manner. Creatively identifies and links patients to appropriate organizational, financial and community resources in order to achieve optimal outcomes and compliance with regulatory agency requirements. Works with departmental leadership to identify the need for and develop resources to achieve optimal outcomes.

3. Provides advanced practice social work interventions. Anticipates and intervenes appropriately and effectively in patient/family crises and ensures implementation of appropriate plans for resolution and care plan follow-up. Provides crisis intervention and emotional support and, when indicated, short-term supportive counseling to patients and family members. Educates others on the healthcare team about the crisis when the disease/hospitalization/ plan of care is impacted, and according to regulations governing confidentiality. Anticipates and intervenes appropriately with patients, family members and/or providers with regard to end of life issues and decision making when appropriate, initiating discussions with the healthcare team as needed. Assists patients and providers with completion of Out of Facility Do Not Resuscitate Orders and MOST forms as needed.

4. Advocates for patients, family members and organization; contributes to the professional development of self and others. Educates other disciplines about the importance of communicating appropriate clinical and psychosocial information to advanced practice social work staff, and intervenes when appropriate. Ensures patients and family members are actively informed of and participating in the care process and are able to make informed decisions about hospitalization and post-discharge care. Advocates for patients' cultural, diversity, and religious beliefs and value systems, and ensures that this information is communicated to others on the healthcare team so that they are incorporated into the care plan; educates healthcare team about the impact of these factors on patients' healthcare decision-making and health and wellness outcomes. Assists with orientation and mentoring new staff and students as requested. Provides on-call and weekend coverage as assigned. Adheres to the National Association of Social Workers' Code of Ethics.

5. Participates in quality improvement. Participates in data collection in accordance with departmental policies and procedures, and with accuracy and within requested timeframes. Reviews, interprets and applies clinical and financial data relevant to assigned patient populations. Maintains awareness of and shares literature relevant to current psychosocial interventions and issues. Recognized as an expert resource; provides ongoing educational opportunities to enhance the knowledge of the healthcare team and/or community with regard to the psychosocial issues of the patient population.

6. Inpatient Social Worker: Develops, implements and revises individualized interdisciplinary discharge plans involving the patient/family, legal representative and health care team. The discharge plans are based on preliminary risk screening and assessment of patient and family psychological risk factors, support systems and coping strategies related to medical condition and post- acute care needs. Addresses complex clinical issues. Anticipates complex psychosocial or clinical issues or behaviors creating or contributing to non-compliance, over-utilization of resources, and/or readmissions. Develops and implements plans of care which enhance quality, access, and cost-effective outcomes. Evaluates and updates patients' progress and identifies and addresses barriers to progression in a timely manner. Ensures patient's participation in the treatment planning process. Creatively works with departmental and organizational leadership and Physician Advisor to address these issues in order to achieve optimal outcomes and compliance with regulatory agency requirements.

7. The ESRD/Transplant Clinical Social Worker- Provides social work services to transplant surgery/potential living donors and new ESRD clients in the acute clinical setting in collaboration with the interdisciplinary team. Responsibilities of this position include working patients/families and the transplant medical/ESRD team and community agencies to coordinate patient care, education and serve as an advocate for the patient/family. The clinical social worker will provide: Information, consultation, and professional support to interdisciplinary team members. Communicate plan discussed on rounds to the members of the interdisciplinary team absent; Complete psychosocial evaluation of potential living donors as scheduled by ECU Transplant Program in the Clinical Evaluation Unit. Psychosocial assessment within 48 hours (72 weekend) of initiation of chronic dialysis for new ESRD patients, as directed. Daily rounds in HDU. Assist with identified needs of the ESRD population, such as outpatient placement, and coordination of discharge needs with inpatient case managers. Collaborate with Nephrologists in the plan of care. Present donor feedback during HDU and Transplant Services rounds. Community Outreach to outpatient dialysis centers for patients and staff involving ESRD and Transplant education.

8. Emergency Department Social Worker- Anticipates the needs of patients and family members related to the emergency room visit and discharge plan; assesses and determines the most appropriate discharge plan for patients who have been released from IVC or requesting voluntary detox services; develops and implements plans of care which enhance quality, access, and cost-effective outcomes. Maintains ED Familiar Faces caseload; evaluates and updates patients' progress and identifies and addresses barriers to progression in a timely manner. Effectively communicates patients and/or family during crisis and traumas. Ensures patient's participation in the treatment planning process. Creatively identifies and links patients to appropriate organizational, financial and community resources in order to achieve optimal outcomes and compliance with regulatory agency requirements. Provides coverage to inpatient units after hours, as assigned. Formulates and communicates patients' needs and prognosis to family members/significant others and coordinates with ancillary family members. Conducts family sessions or family contact in a timely manner. Assesses for and uses appropriate interventions regarding domestic violence, sexual assault, abuse/neglect, involving children and adults, foster care, adoption, guardianship, trauma and other complex psychosocial or medical issues; seeks appropriate consultation with Inpatient/Ambulatory Social Worker, Care Management leadership, Home Health or DSS liaisons, etc.

9. Ambulatory- required prior experience working with a population needing Long term service and support, and/or home- and community-based care coordination, care delivery monitoring and care management, and in social work, geriatrics, gerontology, pediatrics or human services. Assessing social determinants of health including but not limited to transportation, food insecurity, housing, and employment, and linking to appropriate community resources.

10.Rehabilitation- Social work staff serve as the case manager and care coordinator for rehabilitation and ensures compliance with CARF standards. Coordinates delivery of discharge planning and social work services to rehab inpatients. Provides leadership for the interdisciplinary team. Collaborates with the team, community resources and payers to facilitate timely and cost effective discharge plans that enhance health and social services in the continuum of care. Documents patient's progress toward goals. Ensures goals, patient safety plan along with barriers to discharge are discussed at each Team Conference. Presents results to patients and families and documents evidence of discussion in the medical record. Serves as primary contact for patients/families. Identifies patient/family needs and follows through to meet those needs through education efforts, collaboration with others and teamwork all targeted toward predicted outcomes. Keeps patient/family, referral sources, and other stakeholders informed of patient's status related to achievement of goals. Demonstrates knowledge of the rehabilitation programs for each age-specific/diagnostic category. Works with program and division leadership to identify the need for and develop resources to achieve optimal patient outcomes.

11. Other duties as assigned.

Minimum Requirements

Required Masters of Social Work degree from a CSWE accredited school of social work is required.

Preferred Requirements:

2 years of recent experience as a social worker in a health-related environment. Licensed
Clinical Social Worker/Licensed Clinical Social Worker Associate Certification in Case Management.

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.

Contact Information

For additional information, please contact:

D'metrius Dew, Talent Acquisition Consultant

ECU Health Talent Acquisition

Email: [email protected]




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