The Care Manager is responsible for providing coordination of care for patients to support safe, seamless, timely transitions across the continuum. This role utilizes a collaborative process, the care manager identifies (using quantitative and qualitative methods), assess, plan, implement and valuate 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 is responsible for screening, identification, and assessment of individuals in need of active Case Management services and promotes the right resources, at the right time and at the right place.

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, monitors and revises as indicated or when patient condition changes. Completes all necessary care management documentation. Handovers are expected to be utilized at points of level of care change, staff change, weekends as well as care transitions.

• Maintains clear, concise and timely documentation in the patient record (in which CM is providing services to) to reflect physical and functional limitations, psychosocial characteristics, educational needs of patient and family or caregiver, financial, and transitional needs. Initiates referrals to disciplines as indicated. Documentation will reflect plan of care to address post-hospital care needs or resources and evidence of patient, family or caregiver involvement in planning. Ensuring patient’s and caregiver’s treatment goals and preferences are incorporated into the transition of care planning and communicated to the multidisciplinary team.

• Follows standardized practices and processes related to Advance Care Planning, LOS/LOC management, readmission prevention, supports denial prevention related to medical necessity through addressing/removing barriers to progression of care, Interdisciplinary Discharge Rounding, patient satisfaction related to transitions of care, transitional management to the next level of care.

• Supports and promotes assertive, proactive care for inpatients and observation patients, assisting in removing barriers related to achieving timely testing and treatment, and ensures resources are utilized appropriately. If continued treatment can potentially be managed in the ambulatory setting, the care manager will collaborate with the physician and care team offering alternatives to acute care, and escalate to care management leader or physician champion at the facility level if warranted to resolve barriers.

• Works in collaboration with revenue cycle partners to help remove barriers to ensure patients are converted to the appropriate classification as guided by the physician, ensuring CC 44 process is followed.

• Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives within care management. Works collaboratively with peers to achieve facility and department goals and daily work as evidenced by appropriate and timely communication which is respectful and clear. Shares responsibilities, promoting team-based approach to accomplish work. Understands data relative to patient population and utilizes information to improve clinical and financial outcomes, and support facility goals. Strong collaborative partnerships with nursing and physicians, other care team members required.

• Supports and follows compliance rules and regulations such as CC 44, IMM, ABNS, HINs, Moon, Bundle letters, and Conditions of Participation for DC Planning and Utilization Management, 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 such as infection control, risk management, legal or quality management. Keeps facility and CM leadership abreast of potential issues.

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.

Licensing/Certification

BLS Basic Life Support – American Heart Association (required)

Current RN License in the state in which they are working or covered by compact

Preferred: Case Management Certification (ACM, CCM, or ANCC) (preferred upon hire, required within 3 years of hire)

Education

Associate degree in Nursing (required for RNs must start BSN program within 2 years of hire and complete BSN within 5 years)

Work Experience

1 year of experience in clinical setting (required)

1-2 years of experience in an acute care clinical setting (preferred)

Ambulatory or post-acute, care coordination experience (preferred)

Patient Population

Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit.

Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures.​

Neonates (0-4 weeks)

Infant (1-12 months)

Pediatrics (1-12 years)

Adolescents (13-17 years)

Adults (18-64 years)

Geriatrics (65 years and older)

Skills

Care management

Discharge planning

Patient Advocacy

Flexible

Care Planning

Care Coordination

Analyzing data or information

Reimbursement methodologies

Staffing workflow and bed allocation

Clinical knowledge

Tracking

Working knowledge of local and state resources

Knowledge of government and non-government payor practices, regulations, standards and reimbursement

Knowledge Sharing

Attention to detail

Critical thinking

Communication with family members

Conflict resolution

Proactive

Problem Solving

Active listening

Relationship building

Effective problem solving

Teamwork

Facilitation