Primary Function/General Purpose of Position

Responsible for providing coordination of care for patients to support safe, seamless, timely transitions across the continuum. Utilizing a collaborative process, the care manager will identify, assess, plan, implement and evaluate the options and services required to meet an individual’s health and health related needs, including social- determinants that affect ones’ overall wellbeing. The care manager promotes the right resources, at the right time and at the right level of care and is responsible for engaging and supporting patients that would benefit from and need care management services.

Licensing/ Certification

• Acute Registered Nurse (RN) (required)

• BLS Basic Life Support – American Heart Association (required)

• Certification in Case Management preferred and required withing three years of hire.

Education

• Baccalaureate degree preferred and required withing 5 years of hire.

Work Experience

• One to three years nursing experience required. Three to five years nursing experience preferred.

Training

• EPIC Electronic Health Record (preferred)

• Microsoft Excel / Teams (preferred)

Essential Job Functions

• Identifies and prioritizes patients in need of care management services, using a holistic approach inclusive of biopsychosocial, functional, cultural, spiritual, and financial factors. Plans with the patient, family, other caregivers, and other members of the healthcare team to maximize health care responses, quality, and cost-effective outcomes. Completes all necessary care management documentation and handovers. Monitors effectiveness of the plan of care and collaborates with the care team, patient, family/caregiver to revise as indicated. Serves as a patient advocate, as well as an organizational advocate.

• Follows leading, standardized practices and processes related to LOS/LOC management, readmission prevention, supports denial prevention related to medical necessity through proactive progression of care and addressing/removing barriers, daily team rounding informing the care team of risk of readmission and discussing LOS actual vs. goal and plan for the day, stay and way with a projected transition date. Develops, coordinates, and monitors strategies for obtaining resources required for safe and timely care transitions.

• Verifies patient’s needs for acute level of care, collaborating with utilization management nurse to prevent potential denials. The care manager will address when patient is not receiving evidenced based care and escalate to care management leader and/or physician champion at the facility level to resolve barriers.

• Supports and promotes assertive proactive care with Observation stay patients and helps in removing barriers related to achieving timely testing and treatment. Works in collaboration partners to help remove barriers to get patients converted to appropriate classification when appropriate and guided by physician, ensuring CC 44 is delivered when indicated, also closing the loop on CC 44 to ensure tracking and trending.

• Maintains clear, concise, and timely documentation in each patient record to reflect physical and functional limitations, psychosocial characteristics, educational needs of patient and family/caregiver, financial, economic, and transition needs. Initiates referrals to disciplines asindicated. Documentation will reflect plan of care to address post-hospital care needs and evidence of patient, family/caregiver involvement in planning.

• Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives within care management. Works collaboratively with peers to achieve department goals and daily work as evidenced by appropriate and timely communication which is respectful and clear. Sensitive to workload of peers and shares responsibilities, fills in, and offers help promoting team-based approach in order to accomplish work. Understands data relative to patient population and utilizes information to improve quality and reduce cost.

• The care manager shall support and follow compliance rules and regulations and Conditions of Participation for DC Planning and Utilization Review, and address opportunities or potential concerns with leadership. Identifies potential or current patient situations which require referral to other members of the health care team. Keeps leadership abreast of potential issues. 

• The Care Manager will demonstrate commitment to work partners to help each other reach mutual goals and learn from each other. Demonstrates actions and behaviors that consistently promote trust, respect, a positive attitude and promote team morale.

• Care managers proactively engage and educate members of the medical staff and the nursing staff to help them better understand the nuances of transition management, safe alternatives to acute care, proactive progression of care, reimbursement, and the regulatory landscape. 

• Attends appropriate clinical and professional organizations, workshops, and meetings, stays abreast of community resources available to facilitate safe patient transitions of care. Remains current on clinical advancements related to primary patient population, proactively seeks to understand areas/roles outside of immediate area/role within department.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.