Hebrew SeniorLife

Case Manager, Immediate Need

Job ID
Social Services


The Case Manager is responsible for coordinating the care of an assigned panel of patients on our MACU (complex, post acute)  in Roslindale. This is a per diem position, but on a temporary basis, can be scheduled up to 24 hours per week on our Post acute LTACH


Core Competencies:


  • Comprehensive understanding of case management goals.
  • Self-motivated, committed to quality patient experience.
  • Ability to negotiate, procure and coordinate services and resources for patients and families with complex issues.
  • Continual contact with primary care providers, payer sources, patients and families.
  • Sensitivity to competing interests of patients, care team and payers.
  • Maintains patient confidentiality.
  • Develop professional and trusting relationships with patients/residents, families and staff.
  • Use creative problem-solving to meet the needs of others.
  • Act as an advocate on behalf of patients/residents as needed or appropriate                               
  • Communicates with patients/residents/families/visitors and staff in a manner that conveys respect, caring and sensitivity.   
  • Responsible for communicating and responding to issues and problems within a timely and efficient manner.                                                                                                                                  
  • Responds to patients/residents in all situations with a calm, sensitive and supportive approach.
  • Work as a member of the team by pro-actively working to meet patient need
  • Maintain confidentiality of patient/resident information.
  • Meet all requirements as outlined by regulatory and licensure standards


  • Present and obtain signatures on any required admission paperwork (i.e. Notice of Medicare Rights).
  • * Complete documentation including per policy including:
    • Case Management/Social Work assessment,
    • Page 3 of Discharge Referral
    • Medicare Notices of Non-Coverage
    • Important Message from Medicare about your rights
    • Invitations to patient Introductory Patient conferences/Care Plan Meeting
    • Progress notes regarding Team Meetings, Care Plan Meetings, Introductory/Family meetings, discharge planning and routine progress notes.
  • Participate in Team/Care Planning Meetings and collaborates in the planning of care for                 


  • Work closely with the primary care giver, payer sources and various clinical personnel, both in the hospital and the external healthcare continuum.
  • Collaborate with fiscal managers to ensure coordination of a patient’s care across a treatment episode or continuum of care.
  • Negotiate, procure, and coordinate services for patients and families to ensure the facilitation of quality clinical and cost outcomes while promoting optimal, efficient, utilization and allocation of resources.
  • Provide a well, coordinated and documented care experience for patients, families and referral sources through appropriate communications
  •  Anticipate educational needs of patient/resident/family, plans and imparts knowledge to                           meet the needs.
  •   When necessary will advise family on issues relating to Health Care Proxy and/or                                      
  • Assist patient/resident/family, as needed, with financial planning related to potential need for Medicaid
  • Ensure satisfactory clinical outcomes are met.
  • Effectively manage length of stay and resources
  • Integrate and coordinate the activities of multiple disciplines and services throughout the healthcare continuum.
  • Direct and participate with the primary care giver in the ongoing clinical assessment of patient’s status and care management.
  • Participate in the planning of care for assigned patient population in conjunction with medicine, nursing and other clinical staff by formulation a plan of care to address assessed needs and goals concurrently though admission.
  • Support the role and utilizes the clinical expertise of primary care giver.
  • Assess patient’s clinical course to verify patient’s continued need for current level of care in conjunction with patient, family and other members of the care team.
  • Assess and identify in conjunction with patient, family and other members of the team the next appropriate level of care for discharge planning.
  • Collaborate with primary care giver to evaluate effectiveness of plan of care.
  • Collaborate with patient and family to identify needs and goals and communicate this to the health care team
  • Assume responsibility to coordinate input from care team to make changes in plan of care.
  • Participate in interdisciplinary team to ensure coordination of services and resources through post acute stay as well upon discharge/transition of care.
  • Intervene with problem solving and advocacy with staff, referral sources and physicians as is appropriate.
  • Problem solve with case manager internally and externally to insure compliance with care plan.
  • Ensure length of stay is appropriate
  • Insure appropriate resources during stay and at time of discharge.
  • Ensure coordination of all necessary documentation for payer sources.
  • Ensure coordination of all documentation related to discharge and regulatory requirements of both state and federal agencies.
  • Participate in Quality Improvement initiatives




  • Massachusetts RN, LPN, PT, OT, or Massachusetts Licensure as a Social Worker; 
  • Case Management experience required



Working Conditions:


Works in a customer service environment participates in frequent contact with medical personnel, patients, patient families, outside agencies and payer sources.  Includes frequent interruptions, often working in an emotionally charged environment.  Can be subject to exposure to environmental conditions found in a hospital setting.  May be called upon to provide case management services beyond normal business hours.


Physical Requirements


  • Talk on phone for extensive periods of time.
  • Repetitive typing on a keyboard
  • Read computer monitor for a significant amount of time.


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