Case Manager - Acute Care Management - Full Time - Day Shift - Brunswick

Essential Responsibilities:  This description of job responsibilities is intended to reflect the major responsibilities and duties of the job, but is not intended to describe minor duties or other responsibilities as may be assigned from time to time.

Proactively performs case assessment and evaluation to determine possible next level of care. Coordinates care planning and progression. Collaborates with healthcare team members, including medical team to formulate individualized plan of care and discharge plan. Initiates implementation of discharge plan upon initial assessment and coordinates changes to this plan with healthcare team members on an ongoing basis. Consistently and accurately documents plan in medical record and updates documentation as plans are revised. Identifies patients/families with complex psychosocial needs/issues and refers those cases to Clinical Social Work for follow up in a timely manner.

Oversees process/procedure of notification for Medicare and Medicare Managed Care beneficiary’s rights per CMS regulations inclusive of but not limited to:  Notification of Hospital Discharge Appeal Rights, Condition Code 44, Election of Lifetime Reserve Days, Medicare Outpatient Observation Notice, and Hospital Issued Notice of Non-coverage.

Ensures collaboration of healthcare team. Communicates collaboratively on a routine basis during unit/team rounds and throughout the day with the healthcare team members to ensure patient care needs are addressed. Routinely refers appropriate issues/cases to the Physician Advisor in a timely manner. Communicates effectively with peers to assure that patient needs are met, including handoffs and staff covering care. Directs the timely and appropriate referral management tasks to the transportation coordinator and/or Care Management assistant for completion of the transition plan.

Provides documentation of case management processes. Supports other department and healthcare team members in providing appropriate services and effective care by supplying comprehensive documentation in the electronic medical record (EMR) as required by policy. Consistently and accurately documents plan in medical record and updates documentation as plans are revised. Provides comprehensive information to weekend staff to assist them in providing effective follow up and continuity of care. Routinely identifies avoidable days/variances and documents these in the department's electronic system prior to discharge.

Ability to assess and refer patients with medical, psychological, financial and social needs to the SW care manager who will.  advocate for patients with social determinants of health which include, but are not limited to:  abandoned elderly, under/uninsured patients, and patients with extensive medical, social and/or psychological needs, and patients with food/housing insecurity.