Care Manager I

Essential Duties and Responsibilities

• Care Coordination
• Conduct comprehensive assessments of patients' medical, psychosocial, and discharge planning needs.
• Develop and implement individualized care plans in collaboration with the interdisciplinary team.
• Career coordination of services and resources to facilitate safe, effective, and timely transitions of care.
• Maintain patient progress and adjust care plans as needed.
• Advocate for patients and families to ensure access to appropriate services and support.
• Outcomes Management
• Track and evaluate patient outcomes, including length of stay, readmissions, avoidable days, and patient satisfaction measures.
• Identify barriers to achieving desired outcomes and implement interventions to address them.
• Utilize evidence-based practices to improve patient outcomes and quality of care.
• Participate in performance improvement initiatives and quality projects.
• Collaborate with leadership and clinical teams to improve organizational performance metrics.
• Discharge Planning
• Initiate discharge planning upon admission and coordinate ongoing planning throughout the hospitalization.
• Collaborate with patients, families, providers, and post-acute care agencies to ensure safe discharge arrangements.
• Educate patients and caregivers regarding treatment plans, medications, follow-up appointments, and available community resources.
• Ensure continuity of care through effective communication and handoffs.
• Facilitate referrals to community resources, home health, rehabilitation, long-term care, and other post-acute services as appropriate.
• Data Analysis and Reporting
• Review and analyze clinical and operational data to identify trends and opportunities for improvement.
• Maintain accurate and timely documentation in the electronic health record.
• Aid leadership with monitoring key performance indicators and outcome measures.
• Prepare reports related to quality, patient flow, and patient outcomes as requested.
• Support initiatives aimed at reducing readmissions and improving care transitions.

Qualifications

• Education: Registered Nurse (RN), Social Worker (MSW/BSW), or other healthcare professional with appropriate licensure. Bachelor's degree required; Master's degree preferred.
• Experience: Minimum of 2–3 years of case management, care coordination, discharge planning, or related healthcare experience. Experience in acute care, population health, care coordination, or value-based care preferred.
• Certifications: Certified Case Manager (CCM) preferred. ACM, ACM-RN, ACM-SW, or other relevant certification preferred.
• Knowledge, Skills, and Abilities: Knowledge of case management principles, care coordination, discharge planning, and transitions of care. Strong understanding of healthcare regulations and quality improvement methodologies. Excellent communication, critical thinking, and problem-solving skills. Ability to analyze data and identify outcome improvement opportunities. Strong organizational and time-management skills. Proficiency with electronic health records and Microsoft Office applications.