Registry Soc Work Care Mgr IP

Coordinate patient care from admission through discharge, completing thorough psychosocial assessments to foster timely discharge planning. Advocate for patients and families with internal and external stakeholders while identifying barriers to efficient care delivery. Identify and secure post-acute services, completing referrals to appropriate providers and collaborating with Utilization Review to reduce denied services. Participate in interdisciplinary rounds, care conferences, and team meetings to balance patient choice with projected care needs. Educate the care team and patients on transitions of care, readmission mitigation, and available resources while ensuring compliance with federal, state, and payor regulations. Escalate complex cases to management, Physician Advisor, or Ethics committees as appropriate. Work 4 shifts monthly as part of the interdisciplinary team.