- Interviews patients/families to obtaininformation about social, emotional, and financial factors whichmay impact health status both prior to, and after, discharge andassess the patient's current formal and informal support system aswell as available benefits andresources.
- Works with the CMII orCMIII to develop and monitor the patient's plan of care to ensureeffectiveness and appropriateness of services.
- Coordinates/facilitates patient care progression throughout thecontinuum of care in an efficient and cost-effectivemanner.
- Serves as resource, provides support,and acts as an advocate on behalf of the patient related totreatment decisions and end of life issues.
- Closely monitors patient length of stay andcommunicates/collaborates with appropriate interdisciplinary teammembers to remove barriers and expeditedischarge.
- Identifies and escalates local andsystem barriers that are impeding diagnostic or treatment progressand issues related to quality and risk as appropriate in a timelymanner.
- Works to resolve identified delays todischarge.
- Collaborates with medical staff,nursing staff, and ancillary staff to eliminate barriers toefficient delivery of care in the appropriatesetting.
- Assesses needs for discharge planningand continuing care/resource support following discharge;independently makes recommendations to patients and familiesregarding post-acute level of care needs and optionsincluding:
- AcuteRehabilitation Placement
- Nursing Home orSkilled Nursing placement
- Psychiatric orSubstance Abuse placement
- New Dialysis
- Child/Adult/Domestic Abuse
- Home Health/HospiceReferrals
- Legal issues (adoptions,guardianship)
- Assistance with AdvanceDirectives
- Community Resource needs
- Financial Issues/Fundingoptions
- DME Referrals andCoordination
- Social Determinants of Health
- Ensures appropriatecommunication and updates are provided to the patient/family andmembers of the healthcare team and are documented as necessary toassure continuity of care
- Provide appropriateinterventions which demonstrate knowledge of and sensitivity towardcultural diversity and the religious, developmental, healthliteracy, and educational backgrounds of the patientpopulation
- Provides information and support topatients and families, helping them access needed resources withinthe medical center and community
- Ensures andmaintains plan consensus from patient/family, physician andpayor
- Collaborates with the physician and otherhealth care professionals to promote appropriate use of medicalcenter resources
- Actively participates inMultidisciplinary/Patient Care ProgressionRounds
- Escalates cases as appropriate and perpolicy to Physician Advisors and/or CMDirector
- Documents in the medical record perregulatory and department guidelines
- Assumesresponsibility for professional growth anddevelopment.
- Must have excellent verbal andwritten communication and ability to interact with diversepopulations.
- Must have critical and analyticalthinking skills.
- Must have demonstratedclinical competency.
- Must have ability toMultitask and to function in a stressful and fast pacedenvironment.
- Must have working knowledge ofdischarge planning, utilization management, case management,performance improvement, and managed carereimbursement.
- Must have understanding ofpre-acute and post-acute levels of care and communityresources.
- Must have ability to workindependently and exercise sound judgment in interactions withphysicians, payors, patients and theirfamilies.
- Must have understanding of internaland external resources and knowledge of available communityresources.
- Must have the ability to movearound the hospital to all areas for the majority of the workdaywhile in office the rest of the day; general office and hospitalenvironment.
- Graduate of an accredited school of nursing orBachelor's Degree in Social Work (BSW)required.
- Experience in the clinical or acutecare setting preferred.
- LVN/LPN or LBSW in thestate of employment is required.
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Care Manager I - Tyler, United States - Christus Health
Description
Summary:
The Care Manager (CM) I works in collaboration with thepatient/family, physicians and multidisciplinary team members toensure patient progression through the continuum of care and todevelop a plan of care for each assigned patient from admissionthrough discharge. The CM is responsible for identifying,initiating and managing optimal patient flow/throughput to enhancecontinuity of care, smooth and safe transitions, patientsatisfaction, patient safety, and length of stay management.Support and expertise are provided through comprehensiveassessment, planning, implementation, and overall evaluation ofindividual patient needs. Care Coordination and Discharge Planningare both responsibilities of this role. The CM assesses andresponds to patient/family needs by coordinating efforts of otherteam members and identifies and resolves barriers that hindereffective patient care. The CM adheres to departmental andorganizational goals, objectives, standards of performance,policies and procedures, and continually assures regulatorycompliance.
Responsibilities:
Requirements:
Work Schedule:
5 Days - 8 Hours
Work Type:
Full Time
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