Preferred Skills: Psycho/social assessments, knowledge of community resources counseling skills, knowledge of end of life issues. 

PURPOSE: For members of a defined population, responsible for collaborating with the members of the health care team to facilitate the coordination of appropriate, cost-effective services that are consistent with member's plan of care, help achieve his/her optimal level of independence, and enhance quality of life. 
This position consistently supports compliance and the Principles of Responsibility (Kaiser Permanente's Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to the applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente's policies and procedures.

ACCOUNTABILITIES: (List of 4 - 6 primary responsibilities, not activities, in their order of importance)
Provides supportive counseling and education to members, families and caregivers, members of the health care team, health plan staff, and the community, including end-of-life issues and Advanced Directives.
Responsibilities include, but are not limited to, problem identification, psychosocial assessment, financial counseling/referral, accessing community resources, placement for care, guiding the member through health-related legal processes, or consultation and support to other health care professionals.
Effectively manages and coordinates assigned caseload consistent with established criteria. Completes comprehensive psychosocial assessment to evaluate patient goals, social support systems, resources, health status, functional limitations, psychological status, environmental factors, and response to treatment so as to decrease inappropriate utilization of medical services.
In close collaboration with the inpatient palliative care team and other members of the health care team, develops and monitors a plan of care designed to promote the member's optimal level of functioning and enhance the quality of life. 
Identifies, facilitates, and advocates appropriate organizational and community resources to meet the plan of care and ensures that they are implemented for in a cost effective, efficient, and timely manner.
Analyzes patient and program outcomes to identify improvements in program, quality, and cost effectiveness of case management activities.
Promotes self-awareness and knowledge of current case management standards in the community and recent innovations in patient care. Maintains current knowledge of laws, regulations, and policies relating to the practice of social work in the local market/local agencies and maintains high social work standards as defined by the NASW Code of Ethics.

MINIMUM REQUIREMENTS - 
Relevant Years of Experience:
Three years of clinical experience required plus two years in case management.
One year of experience with the defined population required.
Knowledge of community systems and resources in the defined service area preferred.
Experience with computer software programs in a Windows environment preferred.
Knowledge of regulatory issues for the Mid-Atlantic area preferred.

Education and/or Classes:
Bachelor's Degree in Social Work required.
Successful completion of additional training in end-of-life care, including pain and symptom management, nutrition and hydration and hospice care required.

License, Certification and/or Designation: 
Clinical licensure sanctioned by the State to which assigned required.
Case management certification required (or acquired within three years of employment in this position). 
 

 Additional Information: 


 RegionMid-Atlantic 

 Bargaining UnitUFCW - Local 400 

 FacilityM Fair Oaks 

 ShiftDay 

 BenefitedY 

 Employee ReferralN 

 Area of InterestNursing Lic - Inpt RN Other 

 JobTypeFull-Time 

 State/CityVA, Fairfax

 


 Public Department Description:Hospice/ Palliative Care



 
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