In-Patient Case Manager

Seeking an In-Patient Case Manager in Johnson City, TN to join our Clinical Excellence Team. Office hours are typically 8-5, Monday through Friday.

WHO WE ARE:

State of Franklin Healthcare Associates is a physician-led and team member-owned multi-specialty care group of more than 250 providers and 900 team members headquartered in Johnson City, TN with 35 locations in the upper East Tennessee & Southwest Virginia region. Our mission is to improve the health and well-being of our patients and our team members.

PRIMARY RESPONSIBILITIES:

• Coordinates with Hospitalists and Attending Physicians to assist in identifying and determining patients who are appropriate candidates for social work issues, palliative care, or hospice programs.
• Performs daily rounds at hospital facilities to assist SOFHA hospitalists and staff with communication regarding SOFHA Advanced Care Services (Palliative Care) and facilitates discussions regarding care planning and end-of-life care.
• Works in conjunction with SOFHA outpatient clinics to coordinate timely hospital discharge follow-up for patients including referral to SOFHA’s Advanced Care Services team.
• Collaborates to enhance evidence-based clinical guideline adherence and promote best practices by initiating/adjusting therapies and following protocols for patients in the CHF, COPD, and other Chronic Care High-Risk programs as directed by the practitioner and provides appropriate education, follow-up, and monitoring as needed.
• Coordinates with the Hospital Case Manager/Discharge Planner on a regular schedule to identify and determine upcoming discharges and their need for ongoing case management.
• Establishes and maintains an accurate working list of patients, both previously transitioned as well as patients with upcoming transitions, keeping outpatient Case Manager/Care Coordinator aware of pending and high-risk discharges.
• Reviews hospital records, while maintaining patient confidentiality, to help determine discharge plans as well as gather other pertinent information related to the patient’s upcoming transition of care.
• Establishes working relationships with identified inpatient case management populations. Interact professionally face to face, if possible, with patients and/ or caregivers to introduce yourself, build rapport, and explain your role in their transition of care.
• Assesses cognitive, physical, social, and functional status and support system to direct educational goals. Identifies any transportation problems, or environmental issues such as financial barriers to purchasing medications or other prescribed treatments. Any barriers should be reported to the appropriate physician.
• Identifies, completes, and documents any unmet measures (i.e. HEDIS or other contract requirements) within the nursing scope of practice and notifies the Primary Care Physician and outpatient Case Manager/Care Coordinator of unmet measures.
• Facilitates accurate medication reconciliation and transfer of appropriate EMR-related data throughout transitions of care. Ensures patient awareness of follow-up office visits with their Primary Care Physician within 7 days of discharge. Obtains accurate contact information for post-hospital contact.
• Reviews physician-approved care plan/self-management action plan that includes reportable signs and symptoms with contact number and when to seek emergency medical care.
• Educates the patient/caregiver that a nurse from their provider’s office will be calling them within 48 hours upon discharge. Review their discharge and home medications, assess their understanding and compliance with medication therapy, and intervene, if necessary, with medical-related issues. Provides patients with a user-friendly list of current medications before discharge.
• Completes appropriate forms with information such as vaccines received in the hospital, pending lab or radiology results, or upcoming lab or radiology testing that is to be completed post-discharge. This information is sent to the outpatient Case Manager/Care Coordinator upon patient discharge.
• Documents all findings and specifics of care within the electronic medical record (EMR).
• Speaks with the provider as needed regarding discharge plans and any barriers noted during inpatient assessment.
• Coordinates outpatient follow-up plan with outpatient Case Manager/Care Coordinator before discharge from an inpatient setting.
• Assists in providing outpatient Case Manager/Care Coordinator with the following information via EMR:
  • Patient contact information (demographics, PCP, Admission/readmission date)
  • History and Physical (Soarian)
  • Discharge summary (Soarian)
  • Consultations (Soarian)
  • Diagnostics and labs (completed in Soarian) **(IPCM to forward pending results to OPCM when available)
  • Home medication list (Soarian and All scripts)
  • Discharge medication list (Soarian)
  • Identified barriers (financial, caregiver, etc.) that may need follow-up.
  • Referrals to community resources (Home Health/DME) and any specialty referrals
  • Future diagnostics or labs that will be needed post-discharge.
  • Date of follow-up visit with PCP.
• Review the current literature regarding effective teaching/learning strategies and incorporate the appropriate techniques into their patient education sessions.

REQUIREMENTS:

Successful completion of an RN educational program or bachelor’s degree in social work.

EXPERIENCE:

Three or more years of experience in clinical care or case management with hospital experience. Preference given to applicants with prior Palliative Care or Hospice Experience.

WHAT WE OFFER:

State of Franklin Healthcare provides a comprehensive and competitive total compensation package designed to meet the needs of our full-time team members including:

• Company Provided Life and Accidental Death and Dismemberment Insurance
• Company Provided Long Term Disability Insurance
• Employee Stock Ownership Plan
• 401(k) Company Contributions
• Voluntary options for Medical, Dental, Vision, and additional Life Insurance.
• Company match in Health Savings Account Plans (restrictions apply)
• Vacation, Personal, Sick and Holiday Time Off
• An array of team member perks and discounts
• Tuition Assistance Programs
• And more!