Job Description
ESSENTIAL JOB FUNCTIONS:
Primary Duties and Responsibilities
- Manage and plan for transitions of care, discharge and post discharge follow up for patients admitted to key high volume/high priority hospitals.
- Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals. Report variations to PCP/ transitional care physicians (TCP) and implement actions as appropriate.
- Build relationships with preferred acute care providers (hospitalists, specialists).
- Direct referrals to preferred providers.
- Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinate the patient care, discharge, and home planning processes with hospital case management departments, and other healthcare facilities.
- In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital case manager, coordinate the patient transition to the appropriate/least constrictive level of care using a preferred provider.
- Keep the PCP aware of patient condition via e-mail, DASH, HITS or other appropriate means of communication.
- Introduce self to patient/family and explain nurse case manager role and process to contact nurse case manager for questions, guidance and education.
- Provide high intensity engagement with patient and family.
- Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
- Address advanced care planning including treatment goals and advance directives.
- Refers cases to social worker (hospital and JenCare) for complex psychosocial and economic needs.
- Obtain onsite and EMR access at priority facilities.
- Maintain clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
- Submit required documentation in a timely manner and in appropriate computer system.
- Participate in surveys, studies and special projects as assigned.
There are 4 Nurse Case Manager Roles With Additional Essential Job Functions:
Acute Case Manager (primarily hospital based)
- Responsibilities include but are not limited to:
- Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting.
- Coordinate the patient care, discharge, and home planning processes with patient/family, insurance case managers and hospital case management departments, and other healthcare facilities.
- In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital case manager, coordinate and communicate the timely patient transition to the most appropriate/least restrictive level of care using a preferred provider.
- When patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
- Validate appropriateness of inpatient vs. observation status.
- Facilitate discharge to appropriate level of care and preferred providers.
- Coordinate acute UR physician meetings.
Community Case Manager (primarily clinic and community based)
Responsibilities Include but are not limited to:
- Provide telephonic or outpatient visits to patients at high risk for readmissions (as identified by CM Plan) to the ER or hospital, to patients with active care planning requirements, and to others as referred via transitional care team, acute case managers and IDT team.
- Visits may include evening and weekend hours with the goal of preventing ER visits or hospital admissions.
- Perform clinical functions including disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient setting.
Coordinate the Plan of Care:
- Conduct/coordinate initial case management assessment of patients to determine outpatient needs.
- Ensure individual plan of care reflects patient needs and services available.
- Make recommendations to the team.
- Complete individual plan of care with patients and team members.
- Communicate instruction and methodologies as appropriate to ensure that the plan is implemented correctly.
- Assess the environment of care, e.g., safety and security.
- Assess the caregiver capacity and willingness to provide care.
- Assess patient and caregiver educational needs.
- Coordinate, document and follow-up on IDT meetings.
- Report observed or suspected child or adult abuse pursuant to mandated requirements.
- Help patients navigate health care systems, connecting them with community resources, orchestrate multiple facets of health care delivery, and assist with administrative and logistical tasks.
- Coordinate the delivery of services to effectively address patient needs.
- Facilitate and coach patients in using natural supports and mainstream community resources to address supportive needs.
- Maintain ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
- Establish a supportive and motivational relationship with patients that support patient self-management
- Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify home needs.
- Monitor the quality, frequency and appropriateness of HHA visits and other outpatient services.
- Assist patient and family with access to community/financial resources and refer cases to social worker as appropriate.
Community/Skilled Nursing Facility Case Manager (Community Case Manager Role with additional SNF duties as assigned)
Responsibilities include but are not limited to:
- Community Case Manager role as above.
- CM telephonic or onsite visits to SNFs, communication with PT, social workers, patient and families as appropriate.
- Validate appropriate level of care/LOS.
- Validate Discharge plan for safe transition home, utilization of preferred providers or timely transition to long term care.
- PCP 4 day follow-up visit.
- Collaborate with Humana Onsite SNF CM3.
Transitional Case Manager (Blended Acute and Community Case Manager Roles)
Responsibilities include but are not limited to:
- Onsite patient visitation, risk assessment, and care coordination in the acute and community settings.
- Discharge needs assessment and planning.
- Assist patient with engaging community resources.
- Post discharge telephone calls with medication reconciliation.
- Post discharge follow up appointment scheduling.
- Home visits with case management assessment including risk and needs assessments.
- Ongoing monitoring of high risk patients with select conditions (congestive heart failure, chronic obstructive pulmonary disease, etc.)
- Multidisciplinary case conferences.
KNOWLEDGE, SKILLS AND ABILITIES:
- Strong interpersonal, communication and critical thinking skills are required.
- Ability to work autonomously is required.
- Fluent in English.
EDUCATION / SPECIALIZED KNOWLEDGE REQUIREMENTS:
- Certification in case management is preferred. Hospital, healthcare setting experience is preferred.
- Minimum of two (2) years of utilization review, case management, home health and/or discharge planning experience is preferred.
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