Description

JOB PURPOSE:

Coordinates and monitors all Care Management team activities, provides leadership, coaching, and

mentoring to Care Management staff members. Responsible for providing leadership and direction for

Discharge Planning and Transitions of Care, within the acute hospital. Monitors for quality indicators to

assure appropriate social and transitional services are provided to patients and families. Develops and

maintains relationships with physicians, nursing supervisors, payers, community resources/ agencies to

provide the needs services for indigent, uninsured, and underinsured populations.

Qualifications

MINIMUM EDUCATION REQUIRED:

Associate s Degree from accredited school of Nursing or Masters in Social Work and current Social Work

licensure in the State of Georgia.

Minimum Experience Required

Two (2) years of experience in care management, medical social work or transitional care management.

Minimum Licensure/Certification Required By Law

Registered Nurse (RN) or Licensed Master Social Worker (LMSW) and current license in state of GA

Additional Qualifications

KEY RESPONSIBILITIES:

• Provides onsite mentoring, orientation and supervision for Care Management staff to ensure alignment
  
  

with department metrics.

• Communicates with charge nurses, physicians, ED staff and leadership regarding complex discharge
  
  

planning, transitional care, complex psycho/social, psychiatric cases, or high-risk patients that are at

risk for readmissions.

• Provides mediation between the patient, provider, guardians, family members or agencies relative to
  
  

the needs and desires identified by the patient.

• Orient new staff and assist in identifying process improvement opportunities
• Coordinate various aspects of Care Management services; including referral, intake, eligibility
  
  

determination, program planning, monitoring, assessment, and evaluation of needs and services.

• Collaborate with post-acute care providers to secure safe and timely discharges.
• Prepare weekend schedule, monitor PRN staff to ensure compliance w/meeting work requirements.
• Provide guidance and leadership on complex/acute inpatient and ED patients; assist with educating
  
  

ED Staff and collaborate with UR on out of network patients and appropriate diversions.

• Track weekend discharges; discharge delays; escalations, family meetings, etc.
• Huddle with Charge RNs and MDs to address discharge needs.
• Huddle with House Supervisor to discuss bed needs.
• Monitor/Audit regulatory compliance of IMM/Moon notices on the weekend.
• Facilitate weekend huddle to address discharge barriers, Kepro/Medicare appeals and any other
  
  

escalations.