JOB SUMMARY
Coordinates the care and reimbursement of SJH's patient population (inpatient and outpatient) from entry through follow-up treatment. Responsible for supervising the clinical pathway of the patient in the healthcare system. Enhances the quality of patient management, maximizes satisfaction and promotes cost effectiveness of the SJH patient utilizing a multidisciplinary team. Achieves optimal clinical outcomes. Acts as a liaison between patients, their families, providers and services.
ESSENTIAL FUNCTIONS
Care Coordination
· Coordinates and provides care that is safe, timely, effective, efficient and patient centered.
· Admits new patients and determines patient's requirements and needs. 
· Knowledgeable about medical terminology, appropriate levels of health care treatment modalities and the health care delivery system. 
· Promotes quality and cost-effective interventions and outcomes. 
Case Management
· Handles case assignments, creates/reviews/updates discharge plans, reviews case progress and determines case closure. 
· Establishes treatment programs by setting schedules and routines, coordinating services provided and arranging resources including external healthcare organizations and facilities.
· Records case information, fills necessary forms and participates in data collection to show effectiveness. 
· Documents discharge plans according to the Medicare Conditions of Participation and DNV standards. 
· Responsible for monitoring utilization and if necessary, discussing utilization of services with providers and recommending alternative options when appropriate. 
Patient Wellness and Autonomy
· Helps patients to achieve the maximum possible wellness and autonomy through self-determination. 
· Provide emotional support to patients and families. 
· Assess and addresses motivational and psychosocial issues. 
· Establishes treatment programs by setting schedules and appointments, coordinating services being provided and arranging resources. 
· May participate in the Transitions of Care Follow Up Call program as assigned. 
· May, based on Licensure, provide Counseling and/or Crisis Intervention for patients/families. 
Multidisciplinary Team Collaboration
· Develops effective working relationships and cooperation with the medical team throughout the case management process. 
· Presents cases at interdisciplinary care conferences. 
· Communicates regular updates to the appropriate caregivers. 
Performance Improvement
· Will participate in performance improvement programs and quality outcomes data for patients. 
· Assist with data collection, health outcomes reporting and clinical audits. 
· Will promote quality service adhering to compliance policies, privacy, security and confidentiality policies and organizational standards set forth in the Code of Conduct. 
· Maintains compliance with Regulatory Standards and State Statutes. 
Community Resources
· Connects patients with community resources. 
· Provides guidance and referrals for patients who need additional community resources to services such as equipment, meals, mental health, counseling for substance abuse treatment, abuse/neglect, domestic violence, etc. 
· Ensures freedom of Patient Choice and documents same via the Patient Choice Letter. 
JOB REQUIREMENTS
Minimum Education
Required: Bachelor's degree in nursing, counseling or social work
Preferred: Master's in Nursing, counseling, or Social Work
Minimum Work Experience
Required: Recent experience with the discharge process. Flexible and able to adjust to change. Minimum of 3 years of experience in the acute setting. Ability to work with multidisciplinary groups to achieve outcomes. 
Preferred: Previous Case Management experience. Case Management/Care Transitions experience in the hospital setting.
Required Licenses: Current State of Wyoming LCSW license.
FUNCTIONAL DEMANDS
Working Conditions
Possible exposure to blood and body fluids. Hospital environment and office settings. Frequent stressful situations, interruptions, irregular hours, meals and breaks. Possible exposure to chemical/fumes, contagious disease and noise. Ability to adapt to fluctuating work loads. Must be on-site at the SJH campus and other facilities to fulfill the responsibilities of this role. 
Physical Requirements
Includes: sitting, standing, walking, stooping and bending. Able to sit and use computers. Ability to lift a minimum of 30 pounds, push, pull, and reach.