Care Manager II - Case Management

Summary

The Care Manager (CM) II collaborates with the patient/family, physicians, and multidisciplinary team members to guide patients through the continuum of care and develop a plan of care from admission to discharge. The CM identifies, initiates, and manages optimal patient flow and throughput to enhance continuity, smooth transitions, patient satisfaction, safety, and length‑of‑stay management. Through comprehensive assessment, planning, implementation, and evaluation, the CM ensures effective care and compliance with departmental and organizational goals and regulatory standards.

• Meet expectations of OneCHRISTUS
  
  Competencies:
  
  Leader of Self, Leader of Others, or Leader of Leaders.
• Coordinate case‑management functions with hospital departments, external service organizations, agencies, and healthcare facilities.
• Facilitate patient care progression throughout the continuum of care efficiently and cost‑effectively.
• Serve as a resource, advocate, and supporter for patients regarding treatment decisions and end‑of‑life issues.
• Monitor patient length of stay and collaborate with interdisciplinary team members to remove barriers and expedite discharge.
• Implement and monitor the patient’s plan of care to ensure effectiveness and appropriateness of services.
• Identify and report local and system barriers impeding diagnostic or treatment progress and quality or risk issues promptly.
• Proactively identify and resolve delays and obstacles to discharge.
• Use advanced conflict‑resolution skills to ensure timely resolution of issues.
• Collaborate with medical, nursing, and ancillary staff to eliminate barriers to efficient delivery of care.
• Interview patients/families to gather information on social, emotional, and financial factors impacting health status to develop comprehensive discharge planning assessment and care plan.
• Assess needs for discharge planning and continuing care/resource support following discharge; independently make recommendations to patients and families regarding post‑acute level‑of‑care needs, including:
  • Acute Rehabilitation Placement
  • Nursing Home or Skilled Nursing Placement
  • Psychiatric or Substance Abuse Placement
  • New Dialysis
  • Child/Adult/Domestic Abuse
  • Home Health/Hospice Referrals
  • Legal Issues (adoptions, guardianship)
  • Advance Directives Assistance
  • Community Resource Needs
  • Financial Issues/Funding Options
  • DME Referrals and Coordination
  • Social Determinants of Health
• Initiate discharge planning at admission and make post‑hospital service referrals based on assessment and interactions with physicians, multidisciplinary care team, and payors.
• Act as patient advocate by negotiating and coordinating resources with payors, agencies, and vendors.
• Ensure all elements critical to the plan of care are communicated to the patient/family and healthcare team and documented to guarantee continuity of care.
• Provide culturally sensitive interventions and support for patients from diverse backgrounds.
• Assess the patient’s formal and informal support system and available benefits and/or community resources.
• Meet directly with patient/family to develop an individualized care plan in collaboration with the physician.
• Ensure and maintain consensus among patient, family, physician, and payor.
• Provide education, information, direction, and support related to patient goals of care.
• Promote respect for the dignity and rights of every patient while adhering to safety standards and nursing professional practice.
• Collaborate with the physician and other health care professionals to promote appropriate use of medical center resources.
• Provide information and support to patients and families, helping them access needed resources within the medical center and community.
• Actively participate in clinical performance‑improvement activities involving length of stay, resource utilization, avoidable days, cost per case, and readmissions.
• Measure effectiveness of interventions through direct communication with post‑acute care providers, patients, and caregivers.
• Promote individual professional growth and development by completing required mandatory/continuing education and skills competency.
• Actively participate in…