Summary:

The Care Manager (CM) PRN works in collaboration with the patient/family, physicians, and multidisciplinary team members to ensure patient progression through the continuum of care and to develop a plan of care for each assigned patient from admission through discharge. The CM is responsible for identifying, initiating, and managing optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, and length of stay management. Support and expertise are provided through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. Care Coordination and Discharge Planning are both responsibilities of this role. The CM assesses and responds to patient/family needs by coordinating the efforts of other team members and identifies and resolves barriers that hinder effective patient care. The CM adheres to departmental and organizational goals, objectives, standards of performance, policies, and procedures, and continually assures regulatory compliance.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Interviews patients/families to obtain information about social, emotional, and financial factors which may impact health status both prior to, and after, discharge and assess the patient’s current formal and informal support system as well as available benefits and resources.
• Works with the CMII or CMIII to develop and monitor the patient’s plan of care to ensure effectiveness and appropriateness of services.
• Coordinates/facilitates patient care progression throughout the continuum of care in an efficient and cost-effective manner.
• Serves as resource, provides support, and acts as an advocate on behalf of the patient related to treatment decisions and end of life issues.
• Closely monitors patient length of stay and communicates/collaborates with appropriate interdisciplinary team members to remove barriers and expedite discharge.
• Identifies and escalates local and system barriers that are impeding diagnostic or treatment progress and issues related to quality and risk as appropriate in a timely manner.
• Works to resolve identified delays to discharge.
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Assesses needs for discharge planning and continuing care/resource support following discharge; independently makes recommendations to patients and families regarding post-acute level of care needs and options including:
  • Acute Rehabilitation Placement
  • Nursing Home or Skilled Nursing placement
  • Psychiatric or Substance Abuse placement
  • New Dialysis
  • Child/Adult/Domestic Abuse
  • Home Health/Hospice Referrals
  • Legal issues (adoptions, guardianship)
  • Assistance with Advance Directives
  • Community Resource needs
  • Financial Issues/Funding options
  • DME Referrals and Coordination
  • Social Determinants of Health
• Ensures appropriate communication and updates are provided to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and the religious, developmental, health literacy, and educational backgrounds of the patient population.
• Provides information and support to patients and families, helping them access needed resources within the medical center and community.
• Ensures and maintains plan consensus from patient/family, physician, and payor.
• Collaborates with the physician and other health care professionals to promote appropriate use of medical center resources.
• Actively participates in Multidisciplinary/Patient Care Progression Rounds.
• Escalates cases as appropriate and per policy to Physician Advisors and/or CM Director.
• Documents in the medical record per regulatory and department guidelines.
• Assumes responsibility for professional growth and development.
• Must have excellent verbal and written communication and ability to interact with diverse populations.
• Must have critical and analytical thinking skills.
• Must have demonstrated clinical competency.
• Must have ability to Multitask and to function in a stressful and fast paced environment.
• Must have working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
• Must have understanding of pre-acute and post-acute levels of care and community resources.
• Must have ability to work independently and exercise sound judgment in interactions with physicians, payors, patients and their families.
• Must have understanding of internal and external resources and knowledge of available community resources.
• Must have the ability to move around the hospital to all areas for the majority of the workday while in office the rest of the day; general office and hospital environment.

Job Requirements:

Education/Skills

One of the following education is required:

• Certificate, Associate, or bachelor’s degree in nursing
• Bachelor’s or Master’s degree in Social Work

Experience

• Experience in the clinical or acute care setting preferred.

Licenses, Registrations, or Certifications

• LVN/LPN, RN, LBSW, LMSW, or LCSW in the state of employment is required.
• BLS preferred.

Work Schedule:

PRN

Work Type:

Per Diem As Needed