The Case Manager, with an unwavering focus on patient/family self-determination and satisfaction, employs a discharge planning process that manages the transitions from acute to post-acute care and/or coordinates resources for outpatients including medical and community services. The Case Manager proactively and independently guides the health care team toward timely discharge and actively works to eliminate delays in transition. The Case Manager engages the patient/family and multiple providers across varied care settings in the discharge planning process to increase the success of transitions to and from care settings and to reduce readmissions.
Manages a specific case load of patient/family, analyzes patient/family information, assesses and reassesses each patient/family needs and then develops, documents and implements a plan to coordinate those services identified as necessary to optimize transitions and avoid readmissions.
Collaborates with the patient/family and the health care and social service teams in planning, facilitating and advocacy to achieve the expected outcomes for patient/family through promoting access to medical and social systems that support highest possible self-management and/or continuity of care.
Works with the patient/family, providers and payers in understanding and maximizing resources and access to care and support.
Performs per standard work and decision trees. Independently and proactively develops additional processes as needed to meet the needs of the patient/client/family. Shares new processes, creates ideas for improvement, and escalates concerns/problems.
Work Experience BSW/MSW or LVN with 5 years’ experience in case/care management, discharge planning, care coordination. Will consider others with 9 years’ experience in case/care management, discharge planning, and care coordination.
Education/Licensure/Certification Prefer BSW/MSW and must complete the ACM certification within 5 years of hire LVN with experience requirement.