Case Manager

SUMMARY

• Summary: Reports to the Manager or Director of Case Management. Provides coordinated care support to facilitate and expedite patient care services. Participates in daily rounds and collaborates with the clinical healthcare team across the patient care continuum to include preadmission and post hospital discharge. As a member of that team, shares responsibility for the implementation of the discharge plan; ensures efficient and effective delivery of patient care services through the appropriate utilization of healthcare resources. Full time, part time per diem and job share schedules available. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done.
• The core
• Success
• Factors include: Instill Trust and Value Differences
• Patient and
• Community
• Focus and
• Collaborate
• Responsibilities:
• Responsibilities: Partners with medical staff and other members of the healthcare team in collaboration with the patient/family to facilitate the plan of care for a defined patient population across the continuum of care. Identifies a high-risk patient population within the caseload for care management assessment screening and targets interventions in conjunction with the healthcare team within one business day of patient admission Participates in daily care rounds to collaborate with members of the patient 's healthcare team as well as to evaluate and facilitate development and implementation of the discharge planning process. Develops the initial patient discharge plan and reviews with patient, family members and other members of the interdisciplinary team. Reassesses the discharge plan daily during collaborative care rounds. Proactively builds post hospital referrals and sends to the Transition Care Coordinator when indicated to facilitate timely discharge. Delivers Important Message follow-up notices to all Medicare patients according to CMS regulations. Follows CMS and DOH regulations in relationship to discharge guidelines and patient rights. Coordinates the length of stay with the physician care team and patient. Ensures team is informed of insurance qualifiers that may affect the discharge plan. Discuss approaching discharge readiness of patients. Identify and assess readmitted patients and complex patients in collaboration with members of the healthcare team to coordinate discharge. Advocates for the patient and advises the patient regarding financial implications of their discharge plan when coordinating care for the patient. Communicates the discharge plan, including post facilitygency acceptance, to patients, families and all members of the care team. Documents final discharge disposition in progress notes. Develops appropriate patient care reports to ensure safe patient handovers occur as a patient is transferred from one patient care area to the next. Provides care plan direction for the advancement of a patient care delivery system which supports managed care strategies and decreases readmission risk. Acts as a change agent by identifying opportunities to improve patient flow and reduce service delays through problem resolution and follow-up. Demonstrates a fundamental grounding in nursing theory and practice with a clinical background within a defined content area. Remains current on the latest concepts techniques and methods relative to his/her service. Demonstrates knowledge of federal and state rules and regulations. Reviews and acts as a change agent by identifying opportunities to improve patient flow and identifies and reduces service delays through problem resolution and follow-up. Identifies and tracks service and discharge patient delays. Participates in departmental and/or interdepartmental quality improvement activities as requested: i.e. OpX teams weekly long LOS reviews interdisciplinary rounds readmission reviews. Participates in Orienting of New staff as requested. Participates in ongoing education-related professional activities and affiliations to maintain an advanced level of knowledge of patient care services third party payer and managed care requirements and case management.