Hebrew SeniorLife

  • Case Manager - per diem

    Job Locations US-MA-Roslindale
    Job ID
    Social Services
  • Overview


    Position Summary:

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


    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, families and staff.
    • Use creative problem-solving to meet the needs of others.
    •  Act as an advocate on behalf of patients as needed or appropriate                                              
    •  Communicates with patients/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 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 information.
    •  Meet all requirements as outlined by regulatory and licensure standards.
    • Function as a team player inter/intradepartmental





    • 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.
    • Certified Case Manager preferred


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