Case 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.
Seeks feedback on how to improve performance and offers constructive feedback, as well.

ESSENTIAL FUNCTION

Aid patients and families by applying learning for improved performance.
Demonstrate understanding and ownership of how his/her role contributes to achieving the success of the Department and GSPP.
Commit to ensuring a clean and safe working environment.
Use resources wisely – as if they were one’s own.

PATIENT / EMPLOYEE SAFETY ACCOUNTABILITIES

Participates in GSPP and Department wide initiatives for Patient /Employee safety.
Demonstrates an awareness of patient/ employee safety when carrying out daily responsibilities of their position.

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.
• Maintain current knowledge of regulations affecting utilization management and utilization review.
• Facilitate educational programs and advise physicians, and other departments, or regulations affecting discharge planning process.
• Provides utilization management coverage for utilization manager during times of SPTO/USPTO as necessary.