Job Abstract

1. PURPOSE OF JOB:

Ensures collaboration among multiple parties; the patient, family and the multi-disciplinary team (internal and external stakeholders), which may include the payer in an effort to facilitate and coordinate services specific to the patients' needs during an episode of care and/or post-hospitalization. All case manager activities will be client-centric, performed in a proactive manner, require on-going assessment of needs, evaluation of resources, knowledge of associated costs and education as indicated. The case manager is responsible for presenting options in an unbiased fashion to all involved parties and in compliance with HIPAA. Empowerment of the patient or healthcare proxy is expected and maintained so an informed decision regarding continued care needs can be made. Advocacy and education are at the heart of all activities with the basic goal focused on providing best clinical outcomes possible for the patient through evidenced based practice.

2. ESSENTIAL FUNCTIONS:

1. Discharge Planning: Discharge planning is an on-going process that will require the case manager to evaluate and re-evaluate the patient's needs daily or when indicated via interview process and chart review. Discharge planning starts at time of admission and a tentative discharge plan will be addressed in the patient's medical record within 24-48 hours after admission. Assessment and evaluation of the patient needs will be conducted by reviewing current and prior functioning, psycho-social dynamics, and identification of support system. The discharge plan is developed in collaboration with the multi-disciplinary team which may include the payer and will include active input from the patient and/or family. Identification of barriers must be considered in order to facilitate a smooth and successful transition to the next level of care. The case manager will address issues with prior plan of care, specifically with regards to readmissions.

2. Implementation and facilitation of care activities: The case manager will act in a proactive manner addressing real and potential issues with the development and implementation of the plan of care. Documentation of the case manager's activities and discussions should be outlined in the patient's medical record. This might include but is not limited to reaching out to external stakeholders such as the primary care provider and requesting assistance with the development of the plan of care. The purpose would be to overcome any identified barriers to care with the goal being to achieve a successful outcome for the patient. Additionally, the case manager should be verifying benefits and securing authorizations from the payer as indicated and documentation should include facilitation of necessary community resources as needed.

Lastly, advocacy is an important aspect in the case manager's role as he/she must take into consideration the patient's ability to safely maintain themselves in the community or when the patient's capacity is in question. The case manager needs to ensure the patient or healthcare proxy has the ability to fully understand the options of care being presented so an informed decision can be made. Also, this could include acting as a mediator between physicians/consultants and families when conflict arises or a change in status occurs that may put up road blocks to a successful transition to the next phase of care.

3. Data Collection: Case Manager will participate in the collection of information regarding quality improvement activities, risk management issues and reporting this information through appropriate committee structure.

4. Behavioral Expectations: Exhibit consistent professional conduct in interaction with patients/families, medical staff, payers and peers while also respecting HIPAA requirements. Takes ownership for errors and takes immediate corrective action when indicated.

1. QUALIFICATIONS: When considering candidates the director will take into consideration the overall dept skill set and can choose from one of three levels of clinicians for this role acknowledging each discipline will require various levels of supervision and support based on their education, experience and other skills. Disciplines to consider are Registered Nurse, Master Level Social Worker and Bachelor level in Social Work.

Education:

• Registered Nurse: must have a current license in Pennsylvania from the Commonwealth of Pennsylvania, Department of State Bureau of Professional and Occupational Affairs. Bachelor degree preferred.

• Master Level Social Worker: Master of Social Work degree from CSWE accredited school. LCSW preferred.

• Social Worker: Bachelor of Social Work or related field from an accredited school.

Experience:

• Registered Nurse: a minimum of three or more years of acute care clinical nursing. Recent experience in a hospital, insurance company, or independent review company in utilization, quality review, home care or case management.

• Master level Social Worker: a minimum of three or more years in the acute care setting. Previous social work experience or internship in an acute care hospital setting.

• Social Worker: a minimum of three or more years in the acute care setting. Previous social work experience or internship in an acute care hospital setting.

• Other Skills:

  • General Skills All Disciplines: Excellent verbal and written communication skills. Strong organizational and prioritizing skills. Thorough understanding of managed care systems and utilization review criteria. Knowledge of community resources. Demonstrated leadership abilities. Experience in the use of information systems. Must be able to manage and perform well under stress.

  • Certification and Licensure:

    • All disciplines (RN, MSW and BSW) prefer Certification in Case Management (CCM) which reflects advanced education, practice and work experience.

    • Registered Nurses prefer a Bachelor degree in Nursing.

    • Master's level Social Worker prefers LSW or LCSW. Licensure and certification demonstrates a higher level of commitment to their profession and experience through internship and mentoring by another higher level clinician.