Care Manager/ Case Manager

JOB SUMMARY

Develops an integrated link between patients, families, local resources, insurance representatives and hospital, enhances communication among these parties to assure appropriate and timely utilization and access to services and exchange of information, therapeutic interventions and advocates for the rights and needs of patients.

ESSENTIAL FUNCTIONS

• ASSESS PATIENT’S MEDICAL, PSYCHOLOGICAL, EMOTIONAL AND SOCIAL NEEDS
• Interviews patient, completes initial care management assessment, screens for potential discharge planning needs, communicates with treatment team.
• DEVELOP THERAPEUTIC INTERVENTION PLAN ACCORDING TO NEEDS
• Explores options, sets goals, establishes rapport with patient and significant others.
• OBTAIN SERVICES AND RESOURCES FOR PATIENT
• Ascertains appropriateness and refers to community resources.
• Establishes rapport with agencies and support groups.
• Arranges appointments.
• REPRESENTS RIGHTS AND NEEDS OF PATIENTS
• Educates and informs patients about their rights.
• Advocates on their behalf with community resources, insurers, treatment team.
• COORDINATES TREATMENT AND DISCHARGE PLAN
• Led interdisciplinary team meetings.
• Bridges communication between team members, ancillary departments, insurers and significant others.
• MANTAINS DOCUMENTATION
• Appropriate and timely notations in the medical record, departmental files, hand-off communication documents (i.e. POD report), electronic documentation systems and databases.
• ADRESSES PATIENT SAFETY
• Identifies and communicates patient safety issues to the team, patient/family.
• Relays recommendations for a safe discharge plan to patient/family.
• Aids in resolving care issues by making referrals to address identified needs.
• Reports to regulatory agencies as required, facilitates appropriate utilization of services.
• Captures UTILIZATION MANAGEMENT Process
• Reviews clinical information based upon admission and continued stay criteria.
• Performs concurrent medical reviews to communicate to payers.
• Initiates physician advisor reviews for cases not meeting established criteria for admission and/or continued stay to facilitate appropriate utilization of services.
• Communicates denials from third party payers to the physician and coordinates a timely appeals process.
• UPDATES DEMOGRAPHIC INFORMATION, OBTAINS SIGNATURES ON ADMISSION PAPERS AND/OR ADVANCE DIRECTIVES FORMS (WHERE APPLICABLE)
• DEMONSTRATES A PROFESSIONAL DEMEANOR AND MAINTAINS PROFESSIONAL KNOWLEDGE
• Being flexible, responding positively to unexpected changes in the work load and work hours.
• Keeping abreast of regulations and policies related to utilization management and discharge planning, departmental staff meeting information.

QUALIFICATIONS

• To perform this job successfully, an individual must be able to perform each essential function satisfactorily.
• The requirements listed below are representative of the knowledge, skill, and/or ability required.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Education:
• Bachelor's Degree required.
• Master's Degree preferred.
• Work Experience:
• 1-2 years of related experience required.
• Licenses / Certifications:
• Clinical license in appropriate discipline preferred.