Care Manager PRN - Case Management

PRN (as needed) position in the Case Management department at CHRISTUS Health in Tyler, Texas.

About the role

The Care Manager (CM) PRN works in collaboration with the patient/family, physicians, and multidisciplinary team members to ensure patient progression through the continuum of care and to develop a plan of care for each assigned patient from admission through discharge. The CM is responsible for identifying, initiating, and managing optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, and length of stay management. Support and expertise are provided through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. Care Coordination and Discharge Planning are both responsibilities of this role.

Responsibilities

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Interviews patients/families to obtain information about social, emotional, and financial factors which may impact health status both prior to, and after, discharge and assess the patient’s current formal and informal support system as well as available benefits and resources.
• Works with the CMII or CMIII to develop and monitor the patient’s plan of care to ensure effectiveness and appropriateness of services.
• Coordinates/facilitates patient care progression throughout the continuum of care in an efficient and cost-effective manner.
• Serves as resource, provides support, and acts as an advocate on behalf of the patient related to treatment decisions and end of life issues.
• Closely monitors patient length of stay and communicates/collaborates with appropriate interdisciplinary team members to remove barriers and expedite discharge.
• Identifies and escalates local and system barriers that are impeding diagnostic or treatment progress and issues related to quality and risk as appropriate in a timely manner.
• Works to resolve identified delays to discharge.
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Assesses needs for discharge planning and continuing care/resource support following discharge; independently makes recommendations to patients and families regarding post-acute level of care needs and options including:
  • Acute Rehabilitation Placement
  • Nursing Home or Skilled Nursing placement
  • Psychiatric or Substance Abuse placement
  • New Dialysis
  • Child/Adult/Domestic Abuse
  • Home Health/Hospice Referrals
  • Legal issues (adoptions, guardianship)
  • Assistance with Advance Directives
  • Community Resource needs
  • Financial Issues/Funding options
  • DME Referrals and Coordination
  • Social Determinants of Health
• Ensures appropriate communication and updates are provided to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and the religious, developmental, health literacy, and educational backgrounds of the patient population.
• Provides information and support to patients and families, helping them access needed resources within the medical center and community.