Under administrative supervision, collaborates with the specialty and acute care team, medical providers, post-acute care team representative, the patient’s primary care manager, the patient, and the patient’s family to identify and manage proactive care planning and interventions to promote patient wellness and satisfaction during the continuum of care transitions. The following duties are intended to provide a representative summary of the major duties and responsibilities and ARE NOT intended to serve as a comprehensive list of all duties performed by all employees in this classification. Incumbent(s) may not be required to perform all duties listed and may be required to perform additional, position-specific duties. REPRESENTATIVE DUTIES Identifies care management patients by accessing Emergency Department (ED) or inpatient services and establishes personal contact within 24 hours of inpatient or ED referral. Creates and coordinates a focused transitional and discharge plan of care for chronic, high-risk patients based on initial assessment. The assessment is completed in collaboration with the patient, his/her family, direct care providers, primary care manager, post-acute care providers, community agencies, patient housing providers, and other staff as needed. Conducts concurrent medical record review to measure patient progress against goals established for discharge. Prepares and presents cases for discussion at scheduled meetings. Expedites proper sequencing and scheduling of interventions, treatments, and procedures in accordance with the patient’s need during inpatient care. Manages continuity of effective and timely communication between patient and providers. Communicates patient needs with anticipated site coordinator as necessary. Reviews transition/discharge plan to ensure the patient and his/her family understand the plan including medications and discharge needs. Coordinates with pre-authorization and financial counselors for acute and post-acute care as needed. Identifies and communicates any problems or issues that affect patient flow, patient satisfaction, patient safety, length of stay management, or outcomes to the department manager and/or appropriate key stakeholders. Works with acute and primary care multi-disciplinary care team to prevent readmissions; identifies and communicates relevant information and facilitates care conference(s) as necessary. Displays innovation in problem solving and critical thinking Assists leadership in Transitional Care Program development and continuous improvement through measurement and feedback of appropriate outcome based processes and strategies. Actively participates in developing program structure, tools, procedures and communication strategies. Recommends changes for process improvement in program policies and operations to meet objectives. Performs other duties as assigned or required. Transitional Care MSW Case Manager II Coordinates with local and State agencies as needed for care coordination; this may include the Office of Children’s Services (OCS), Adult Protective Services (APS), etc.

Required Skills

Knowledge of Alaska Tribal Health System, ANTHC, and Alaska Native culture(s) and politics. Knowledge of multiple care environments – Inpatient (IP), Outpatient (OP), Emergency Department (ED), Skilled Nursing Facility (SNF), and Home. Knowledge of the healthcare system and its component parts including sites of care, delivery models, and the roles of various providers and health care professionals. Knowledge of the community-based social service delivery system and its interaction with the health care system. Knowledge of working with multi-cultural populations. Skill in assessing and prioritizing multiple tasks, projects, and demands in a high stress environment. Skill in managing patient complexity and multiple patients with diverse needs. Skill in working on teams to plan and produce defined outcomes within given timelines. Skill in thinking broadly and longitudinally, constantly assessing and anticipating the needs of the patient and his/her environment. Skill in managing patient complexity and multiple patients with diverse needs. Skill in working independently with flexibility and adaptability. Strong clinical skills, including an understanding of and ability to implement evidence-based care. Skill in establishing and maintaining effective professional working relations with co-workers, providers, and representatives of other health care organizations. Skill in ability to collaborate and facilitate relationships and consensus among the patient, family, and multidisciplinary providers from many different disciplines.

Required Experience

MINIMUM EDUCATION QUALIFICATION A Master’s Degree in Social Work. MINIMUM EXPERIENCE QUALIFICATION Transitional Care MSW Case Manager I Non-supervisory – Two (2) years of experience in social work. Transitional Care MSW Case Manager II Non-supervisory – Three (3) years of experience in social work. MINIMUM CERTIFICATION QUALIFICATION Current Basic Life Support (BLS) card. Transitional Care MSW Case Manager II Current Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) in the State of Alaska. PREFERRED EDUCATION QUALIFICATION N/A PREFERRED EXPERIENCE QUALIFICATION  Experience in the Alaska Tribal Health System.  Experience in an acute care medical setting. PREFERRED CERTIFICATION QUALIFICATION  Nationally recognized case management certification is preferred. ADDITIONAL REQUIREMENTS N/A WORKING CONDITIONS The following demands are representative of those that must be met by an employee to successfully perform the essential functions of this job:  Must be able to lift approximately 20 pounds.  ANMC is not a latex free environment. Therefore, some latex exposure can be expected.  Work involves the potential for exposure to infectious diseases.  May be required to work outside the traditional work schedule. This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice.

Knowledge of Alaska Tribal Health System, ANTHC, and Alaska Native culture(s) and politics. Knowledge of multiple care environments – Inpatient (IP), Outpatient (OP), Emergency Department (ED), Skilled Nursing Facility (SNF), and Home. Knowledge of the healthcare system and its component parts including sites of care, delivery models, and the roles of various providers and health care professionals. Knowledge of the community-based social service delivery system and its interaction with the health care system. Knowledge of working with multi-cultural populations. Skill in assessing and prioritizing multiple tasks, projects, and demands in a high stress environment. Skill in managing patient complexity and multiple patients with diverse needs. Skill in working on teams to plan and produce defined outcomes within given timelines. Skill in thinking broadly and longitudinally, constantly assessing and anticipating the needs of the patient and his/her environment. Skill in managing patient complexity and multiple patients with diverse needs. Skill in working independently with flexibility and adaptability. Strong clinical skills, including an understanding of and ability to implement evidence-based care. Skill in establishing and maintaining effective professional working relations with co-workers, providers, and representatives of other health care organizations. Skill in ability to collaborate and facilitate relationships and consensus among the patient, family, and multidisciplinary providers from many different disciplines.