Care Manager

PATIENT / CUSTOMER

• Ensures communication and collaboration with supervisors and fellow co-workers to serve patients and other customers to the best of his/her ability.
• Is professional in all actions and appearance.
• Anticipates patients’/customers’ needs and acts accordingly.
• Works to enhance patient satisfaction.
• Analyzes problems from the customers’ point of view.
• Honors patient/customer/employee confidentiality.
• Sets and offers constructive feedback on how to improve performance.
• Assist patients and families.
• Applies learning for improved performance.
• Demonstrates understanding and ownership of how his/her role contributes to achieving the success of the Department and GSPP.
• Demonstrates a personal commitment to ensuring a clean and safe working environment.
• Uses resources wisely – as if they were one’s own.

OPERATIONS

• Responsible for planning, organizing and evaluating interventions and their effect on the discharge outcome.
• Lead weekly team conferences to coordinate patient care and discharge planning with the interdisciplinary team.
• Document as appropriate in EMR platform.
• Initial and ongoing psychosocial assessment to identify potential discharge needs and develop a discharge plan.
• Ascertains patient’s medical, psychological, emotional, and social needs are obtained and addressed by the interdisciplinary team.
• Documentation of admission in appropriate EMR platforms.
• Prepare the patient and the family for discharge.
• Ensures family education is completed prior to discharge.
• Establish family conferences as needed/required.
• Provide patients/families with information regarding choice of next level of care.
• Arrange for post-discharge services: home health care services, durable medical equipment delivery, access to medications, skilled nursing placement, referrals to community resources.
• Work with case management team to improve the awareness of resources available to support the transition of patients into their community.
• Arrangements for transportation at the time of discharge, and continued in the community setting.
• Inform patients of their rights under CMS/Medicare guidelines.
• Promote utilization of available resources to achieve cost effective outcomes.
• Maintains current knowledge of regulations affecting utilization management and utilization review.
• Facilitates educational programs and advises physicians, and other departments, or regulations affecting discharge planning process.
• Provides utilization management coverage for utilization manager during times of SPTO/USPTO as necessary.