Case Manager

PRINCIPLE DUTIES/ESSENTIAL FUNCTIONS:

· Develops a comprehensive social history and assessment of the resident that includes: problems and strengths, special needs and preferences (social, religious, and or cultural) and the implications for the care plan.

· Tracks and maintains every patient case including; ongoing clinical & rehab skilled needs, barriers to progress or discharge, anticipated discharge destination and date.

· Communicates with physicians, members of the Interdisciplinary team and other agencies to coordinate optimal care and resources for the patient/family

· Maintains regular communications with the unit manager, therapy services, MDS and Social Worker to review care and participate in the discharge process

· Attends the Interdisciplinary Risk meeting and other patient conferences as deemed necessary

· Functions as a liaison between all HMO disciplines approving skilled level care for skilled residents

· Updates external case manager with scheduled updates/concurrent reviews as well as changes in resident’s plan of care

· Responsible for generating and maintaining ACO, ALOS and hospitalization reports

· Facilitate the Discharge Planning Meeting and Utilization Meetings

· Maintains the patient medical record and other documentation in accordance with industry standards. Records problems, plans, actions and goals accurately and concisely in the patient record so that changes are reflected as they occur

· Communicates with patients, their families, physicians, health and other service providers, medical suppliers, payors and members as needed; coordinates follow up appointments and necessary medical follow-up

· Reviews and educates resident/responsible party around disease process, discharge instructions and medication listing, 30-day window for readmissions prior to discharge

· Identifies and issues Medicare non-coverage letters for Part A and managed care beneficiaries. Issues Residents Rights regarding transfers and notice of transfer/discharge to resident. Leaves copies to be scanned for ombudsman.

· Responsible for all things medical – Orders DME (O2, nebulizer, wound vac), makes VNA/Home care referrals

· Coordinates patient care by all service disciplines in skilled LOC

· Completes discharge paperwork

· Participates in quality management and safety activities

· Performs duties according to the standards of nursing practice

· Adheres to policies and procedures set forth by the industry

· Performs other duties as required

QUALIFICATIONS:

· Bachelor’s Degree preferred

· Currently licensed as a Nurse in the state of MA

· At least five years of Case Management Experience preferred

· Demonstrated commitment in the Culture of Excellence philosophy

· Current valid driver’s license

· Current CPR certification