Case Manager/ Discharge Planning

Performs intake assessment on patient within 24 hours of admission (patients meeting screening criteria).

Develops, implements and evaluates individualized patient care plans to meet the needs of patients.

Reviews care and treatment for appropriateness against screening criteria and for infection prevention and control, quality and risk assessment; documenting same in computerized database.

Performs follow-up assessments per Case Management Plan and/or department policy.

Utilizes clinical pathways whenever ordered by physician, to facilitate coordination of patient care.

Evaluates patient care plans on a regular basis and updates the care plans when needed.

Plans patient care in collaboration with all members of the healthcare team.

Consults with other departments, as appropriate, to collaborate in patient care and performance improvement activities.  Collaborates with other departments to identify operational problems and develop solutions/resolution.

Works with all members of the healthcare team to assure a collaborative approach is maintained in care and treatment of the patient.

Works closely with social worker to integrate psychosocial management of patient/family needs.

Continues contact with patients with chronic diagnoses to assist with life style changes as needed to prevent recurrence or exacerbation of chronic illness.

Meets with the patient and family to assist with disease management planning.

Keeps patient informed of progress and provides information related to disease progression.

Educates patient and family on all aspects of patient’s hospitalization, following the healthcare plan and continuing care.

Responsible for authorization of appropriate services for continued stay and through discharge.

Coordinates specialties when appropriate for optimal patient care.

Orders and arranges for home care equipment, healthcare needs as necessary.

Works with third party payers to validate need for patient care and home care environment needs.

Reviews patient care activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services.  Assures that the outcome of review is appropriately maintained in the computer database.

Assumes responsibility for timely completion of required case management reports for  hospital leadership, regulatory bodies, health plans, insurance carriers, etc.

Possesses knowledge of Medicare, Medicaid and private insurance providers.

Coordinates the discharge planning function in conjunction with the social worker; assist Quality Management Coordinator and Risk Manager with screening, investigation and problem solving as needed.

Assists the Utilization Management Department with all utilization activities as requested and directed.

Participates in education on and implementation of clinical guidelines and protocols.

Functions as a patient/family advocate ensuring each patient receives the most cost-effective care possible.

Documentation meets current standards and policies.

Maintains optimal continuum of patient care through efficient and effective planning, assessing and coordination of healthcare services.

Demonstrates an ability to be flexible, organized and function under stressful situations.

Maintains a good working relationship both within the department and with other departments.

Supports and maintains a culture of safety and quality.

Remains current on case management theory and practice, psychosocial issues current within the community and the healthcare environment.