The Complex Case Manager works across facilities to manage discharge planning for socially or medically complex patients who have barriers that complicate their discharge. Examples include but are not limited to: Guardianship, homelessness, behavioral issues, lack of insurance. Primary function is to manage the most medically or socially complex patients.
JOB DUTIES AND RESPONSIBILITIES:
Manages a caseload of high-risk patients including readmissions, high utilizers, and patients with complex social or medical needs.
Caseload can consist of cases that span more than one campus.
Acts as a resource for other care managers and the treatment teams on complex patient issues affecting discharge.
Completes standardized documentation to ensure consistency and compliance with regulations.
Assists patients in accessing community resources, outpatient follow-up, and social support services to facilitate care across the continuum as well as reduce unnecessary readmissions.
Attends guardianship hearings or other meetings outside of a hospital setting as necessary for the caseload of patients.
Organizes and facilitates team meetings with patients, families and members of the healthcare team as needed to coordinate care.
Facilitates transitions to outpatient services, which include but are not limited to home care, post-acute facilities, or other post-acute services.
Collaborates with the patient, family or other caregivers and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals.
Facilitates communication among all treatment team members.
Manages length of stay and readmissions by proactively identifying and mitigating issues and barriers to care and a successful discharge plan.
Updates the care team, patient/family as to the status of the discharge plans. Re-evaluates and revises the discharge plan as additional information is acquired.
Proactively considers options such as palliative care, homecare and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of readmissions.
Issues applicable state/federal regulatory notices as applicable ie.) Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle Payment Care Initiative (BPCI) notification.
Monitors risk assessments using available tools and implements discharge interventions accordingly.
Coordinates utilization of patient and community resources to facilitate achievement of a safe and effective discharge plan and accomplishment of goals as well as minimizing risk of readmission.
Provides supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement.
Maintains confidentiality of all protected health information (PHI), St. Luke’s proprietary information, and secures release of information when appropriate.
Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.
Demonstrates/models the Network’s Service Excellence Standards of Performance in interactions with all customers (internal and external).
Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.
Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.
Complies with Network and departmental policies regarding attendance and dress code.
Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient treated.
Seeks out educational opportunities specific to the role of care management.
Other related duties as assigned.
PHYSICAL AND SENSORY REQUIREMENTS:
Sitting for one to two hours at a time, walk on all surfaces for up to five hours a day, and climb stairs. Occasionally firmly grasp, twist, and turn objects with hands and fingers. May be required to lift, carry, push, and/or pull objects weighing up to 50 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Staff must have the ability to hear as it relates to normal conversations and high and low frequencies and to touch as related to telephone and computer keyboard.
EDUCATION:
RN or MSW. ACM certification strongly preferred.
TRAINING AND EXPERIENCE:
Minimum of 3 years FT case management experience in an acute care setting. Strong knowledge of care transitions, discharge planning, and community resources. Ability to work independently and collaboratively in a fast-paced environment.
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!