Hebrew SeniorLife

  • Case Manager - Per Diem

    Job Locations US-MA-Roslindale
    Job ID
    Nursing - Licensed
  • Overview

    The Case Manager is responsible for coordinating the care of an assigned panel of patients.


    • 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 patients      
      • 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/family, plans and imparts knowledge to meet the needs.
    • When necessary will advise family on issues relating to Health Care Proxy and/or guardianship.
    • Assist patient/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, or Massachusetts Licensure as a Social Worker; RN preferred for the MACU
    • Case Management experience preferred
    • At least two years of nursing or social work experience in medical, surgical, or rehabilitation units.



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