Case Manager Extender - PRN - Transitions of Care Dept

** Job Summary :
** The purpose of the case manager is extender is to serve patients who have been discharged from the hospital or are to be admitted to the hospital. Focus is on the facilitation of the transitions before and after the acute episode of care, with attention to medical, psychosocial, and economic concerns. Particular attention is paid to those with preexisting and chronic care conditions and functional limitations to assist in navigating the system to decrease fragmentation, duplication and inefficiencies and promote coordination of comprehensive services, increase patient engagement and satisfaction, and enhance optimal health outcomes and quality of life for patients.  

The case manager extender performs activities as an adjunct to the case managers, as well as overall department functioning.
** Job Description
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* ESSENTIAL RESPONSIBILITIES:

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* Note:

While these are considered essential responsibilities of the position this is not a comprehensive inventory of all duties and does not take into considerations accommodations that may be required as situations require.  Case manager extenders are assigned functions based on applicable education and expertise and will not perform all activities pertinent to the role of the RN or SW case manager.
*** Participation in departmental, hospital and community meetings and initiatives concerning transitions of care.

• Assessment and development of initial screen and evaluation for non-complex planned admissions under the supervision of an RN or SW case manager for.

• Facilitate access to service and resource brokering (SNF, home care, hospice, infusion, LTAC, DME, transportation, etc) for maximization of optimal health care outcomes pre and post admission.

• Reassessment of plan and monitoring for changes in condition for low-risk patients.

• Partnership development and sustainability with physician practices and outpatient service providers and pertinent community services.

• Act as point person for post-acute care providers concerning issues with provisions of care.

• Act as a point person for the HRH Physician practices concerning provision of care.

• System integration/continuity of care and interdisciplinary collaboration.

• Maintains accurate information concerning contact persons with community partners.

• Medicare Important Message and Observation letters.

• Float as assigned by TOC clinical manager and TOC team leaders.

• Utilization review and case management assignments for inpatients and those receiving outpatient services as requested.

• Attention to accuracy and completeness of disposition coding and After Visit Summary.

• Participation in departmental, hospital and community meetings and initiatives concerning transitions of care.

• Management of department resources including the TOC DME Loaner closet.

• Department communication including addressing phone calls and visitors to the department main office.

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the associate for this job. Duties, responsibilities and activities may change at any time with or without notice.
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* SKILLS AND ABILITIES:

***** Comprehensive knowledge of healthcare industry.
* Familiarity with government regulations concerning discharge planning, abuse, advanced directives, safety and privacy.
* Trained in promotion of patient and family engagement.
* Ability to think logically and to process complex information.
* Fiscal responsibility in allocation of hospital resources.
* Ability to read and to communicate well in writing and ability to use a computer.
* Ability to relate well to and effectively communicate with a diverse patient population, family members, physicians, other associates, individuals in the community, community agency and nursing facility representatives and all other identified customer groups.
* Ability to gain the trust and confidence of patients and family members and other customer groups.
* Ability to empathize with others.
* Ability to respect the rights of others, to treat others with dignity and to hold a belief in the right of the individual…