Case Manager BSW

US-IA-Windsor Heights
2 months ago
Job ID
# of Openings
PACE Pathways


Purpose of the Job:
The primary responsibilities of this job includes the coordination, facilitation, and transition of PACE participants who are admitted to the hospital, in short-term or skilled rehab care, or long term care.  In addition, the Case Manager BSW plans, organizes and implements social services to Immanuel Pathways participants and families. Responsibilities include but are not limited to: review of assessments completed by the Master of Social Worker (MSW) and supports the treatment plan, teaching and counseling to participant, caregiver or other appropriate representatives under the supervision of the MSW.  Social work interventions could include individual participant contacts; appropriate collateral contacts; participant and family education; assigned counseling; provision of resources; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures under the supervision of the MSW.  The Social Worker may be the assigned liaison between the caregiver representatives and community agencies. Supports and lives out Immanuel’s Mission and CHRIST Promises.



Key Areas

Key Responsibilities and Duties of the Job

Case Management


  • Facilitates the exchange of relevant participant information to include but not limited to the file of life, facility admission orders, advance and present directives, and care plan, between Immanuel Pathways and the contracted facility to establish continuity of care.
  • Performs a visit to hospital, SNF or participant home within 24 business hours, or the next business day in the event of a weekend or Holiday admission to ensure participant and/or family needs are being met and questions are answered.
  • Communicates with acute care, sub-acute and long term care facilities regarding status of participants and discharge planning needs.  Facilitates communication of related information to the interdisciplinary team, providing daily updates, for the IDT Meetings or Healthcare Huddles.
  • Participates in Nursing Home rounding and care plan meetings to monitor status of and communicate with IDT regarding the participant’s care.
  • Collaborates as a member of the IDT in decision making and documentation regarding these plans. 
  • Documents care coordination information in the participant’s electronic health record (EHR) in a timely manner in accordance with Immanuel documentation standards.
  • Monitors status and services of participants at contracted facilities, to ensure participants are maintained in the most appropriate setting while promoting independence, safety, and quality of care.
  • Manages participant admission and discharge process in the EHR, including status updating within RX system for the purpose of medication tracking.
  • Completes PASRRs with the State of Iowa for care transitions.
  • Completes Case Activity Reports (CARs) for the State of Iowa for the purposes of extended hospitalizations and nursing home placement.
  • Facilitates hospice or nursing home placement as needed or requested. Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies.  Advocates with these entities for purposes of maintaining community stability.
  • Monitor participants weekly the first 30 days of transitioning from one care setting to the next including, but not limited to the nursing home admission or discharge and hospital discharges, to ensure seamless coordination of services.
  • Develops relationships with discharge planners in the network.

Direct Participant Support


  • Reviews the completed assessments for enrollment of potential Immanuel Pathways participants.  Provides assistance to the MSW in carrying out the interventions and goals identified in care planning to address the psychosocial history, which may include descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other issues and needs. 
  • Supports the interventions and goals identified in each comprehensive plan of care for each participant.  May attend and participate in team meetings; communicates participant changes, reports on plan of care decisions and coordination for twenty-four (24) hour care delivery. In collaboration with the MSW, coordinates and follows the designated and outlined process for transition back to pre-PACE programs and services, following a voluntary or involuntary disenrollment. 
  • Provides ongoing support, counsel, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model and PACE health services.
  • May be required to perform home visits based upon an individual’s Plan of Care in regards to state applicable Home Health standards and Regulations.
  • Provides support to the participant and caregivers regarding orientation to, and ongoing relations with Interdisciplinary Team, Participant Center staff, and other Immanuel Pathways staff, including volunteers under the supervision of the MSW.
  • May attend and actively participate in a variety of organizational meetings related to participant care, including but not limited to:  IDT meetings, Intake and Assessment meetings, various in-services and community agency meetings.
  • Assists participants and caregivers in filing grievances.
  • Works to maintain participant housing through intervention with participant, caregivers and housing.  Will proactively work to partner with participant and/or caregivers to maintain appropriate housing and assist participant to function at most independent community level possible. 
  • Analyzes inpatient and skilled nursing utilization data available to ensure appropriateness of medical necessity of services requested and received.
  • Identifies and escalates quality of care issues through appropriate channels.
  • Collaborates with inpatient medical team and skilled nursing teams to secure appropriate options and necessary services
  • Collaborates with Provider Relations Specialist to educate contracted vendors on the PACE philosophy and model of care.
  • In the event of termination of the PACE organization, the Social Worker will act to coordinate the transitional care necessary, under the direction of the MSW, to ensure continuation of care during and after termination.  Assists participants in obtaining reinstatement of conventional Medicare, and Medicaid benefits, transition participants care to other providers, make all appropriate referrals make the participants medical records available to new providers with appropriate participant approvals.

10% Compliance

  • Acts within the scope of his or her authority to practice.
  • Implements Exposure Control Plan.
  • Complies with Emergency Preparedness Plan.
  • Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families. 
  • Participates in and supports Quality Improvement Initiatives.
  • Completes internal or external ISIS PACE Reviewer training.
  • Completes Security Review process for system access in the respective state in which he/she is employed.
  • Maintains up to date knowledge of system/process and communicates to IDT as applicable.

5% Other

  • Acts as a resource to other team members and Participant Center staff regarding topics such as dementia, difficult behaviors, and difficult personalities. 
  • Participates in continuing education classes and any required staff and training meetings.
  • Maintains professional affiliations and any required certifications. 
  • Performs other duties as required or requested.




  • Bachelor’s Degree from an accredited school of social work is required.



  • Two (2) years of experience working on a multidisciplinary team in the healthcare field, with hospital experience, preferred.
  • One (1) year of experience working with frail or elderly population required. 

Other Requirements-

  • Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
  • Basic Life Support (BLS) current certification.
  • Must have a valid driver’s license, proof of insurance and have reliable means of transportation.

 KSA- Knowledge Skills and Abilities-

  • Knowledge of psychology in analysis, intervention and counseling with individuals or in small group conferences.
  • Skilled in counseling techniques, mentoring and coaching, and/or training methods.
  • Knowledge of local and state healthcare and aging networks; in the respective state in which he/she is employed.
  • Skilled verbal and written communication, including speaking to groups of people.
  • Ability to chart via Electronic Health Records, including navigation of Mercy’s One Care EHR system.
  • Proven experience and basic computer proficiency (internet, email, Microsoft Office).
  • Ability to work with frail/chronically ill elderly people.
  • Ability to provide psychosocial assessment and individual, family and group counseling.
  • Ability to maintain accurate records and to prepare clear and concise reports, correspondence and other written materials.
  • Ability to communicate clearly and effectively.
  • Skilled in establishing and maintaining effective working relationships with physicians, participants, co-workers, and the public.
  • Skilled in facilitating group interaction, decisions and implementation processes.
  • Ability to effectively and efficiently plan, prioritize and follow-up on delegated responsibilities.
  • Ability to apply creative problem-solving and critical thinking skills to complex issues.
  • Ability to work independently with minimum supervision.
  • Ability to plan effectively using proactive approach, keeping appointments and following through on commitments.


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