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.