- The Case Manager plays a crucial role in facilitating the interdisciplinary team to plan, coordinate, implement, and evaluate patient care for the assigned service line across the continuum of care.
- Collaborates proactively with Quality Improvement Teams, patient care standards, Social Work, and utilization management to ensure the optimal use of resources for achieving maximum clinical and financial outcomes.
- Participates in maintaining quality care and performance improvement through leadership, problem solving, decision making, and outcome measurement.
- Acts as a valuable resource for the health care team, community, patient/significant others/family, and payers by serving as a clinician, consultant, advocate, and educator for the assigned service.
- Coordination of Care:
- Assists in ensuring coordination of care across the continuum of care pre and post-op in the hospital.
- Monitors patients' progress proactively through patient care standards and evidence-based guidelines.
- Collaborates in the management of care across the continuum, including discharge planning, length of stay, and resource utilization.
- Provides leadership and guidance to formulate individualized care plans by utilizing knowledge and evidence-based guidelines.
- Participates in care conferences for patients with complex issues.
- Facilitates patient and family education for continuity of care.
- Demonstrates expertise in the referral process and community resources.
- Identifies high-risk patients for appropriate collaboration and resource allocation.
- Quality Improvement:
- Implements strategies to optimize patient health status and reduce length of stay/resource consumption.
- Assesses educational needs and conducts learning opportunities for health care professionals.
- Works on continuous improvement of patient care outcomes while reducing costs.
- Ensures communication with community agencies and reports aggregate variances for patient care services.
- Collaborates with the team to analyze variances and develop strategies for improvement.
- Requirements:
- Preferably has acute care nursing experience.
- Experience in case management, utilization management, or discharge planning/home care is beneficial.
- Strong problem-solving and critical thinking skills.
- Basic computer system knowledge applicable to utilization review processes.
- Willingness to engage in performance and quality improvement initiatives.
- Open communication and customer/patient satisfaction focus.
- Respects individual differences and backgrounds.
- Requires on-site presence as the work cannot be done remotely.
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Description
Care Management/Social Work