Care Manager

Major Responsibilities

Coordinates patient care activities ensuring efficient utilization of interdisciplinary resources.

• Selects approaches in care coordination that reflect knowledge and integration of regulatory agency standards.
• Manages resources in collaboration with patients, families, the health care team, and the community.
• Develops and evaluates methodologies for efficient communication among unit nursing personnel and interdisciplinary team members.
• Evaluates scheduling of patients/procedures to provide timely and customer‑focused services.
• Participates in the resolution of hospital‑based issues which affect patient care outcomes.
• Facilitates patient movement through the system in a timely manner by fostering collaboration with care providers at points of transition.
• Works collaboratively with internal and external customers. Serves as a liaison between the inpatient rehab unit, subacute facilities, home health agencies and outpatient services.
• Interfaces with Utilization Management and insurance providers.
• Strengthens and/or creates existing, collaborative, non‑binding relationships with other sites of care.

• Assesses plan of care to assure care is based on accepted standards and current research (evidence‑based practice).
• Evaluates the patient’s progress against the established outcomes, interventions, pathways, algorithms, and guidelines, and modifies the plan of care to meet the individual goals of the patient.
• Coordinates/participates in interdisciplinary patient care conferences to ensure the most appropriate plan is made based on patient need and resources.
• Gathers data and measures trends that affect quality outcomes and complies with regulatory standards in coordination with the Rehabilitation Services Leadership and regulatory bodies.
• Collaborates with team members to develop and implement written plans of care, pathways, algorithms, and guidelines.

• Facilitates patient/family participation in self‑care based on age and developmental status.

• Identifies patients with discharge planning needs by using high‑risk criteria and referring those patients that meet the criteria to Social Work.
• Monitors patients’ progress and helps advance patients to the next level of care.

Determines when a patient is ready for outpatient services.

• Ensures appropriate consults with team members, e.g., wound care, ethics, MD specialists.
• Coordinates pre‑discharge teaching with staff and home care, if appropriate.
• Participates in teaching of patients and families.
• Serves as a resource to Patient Intake in relaying pertinent patient care information.

• Develops system for reporting variances to medical director, clinical manager, and interdisciplinary team members.
• Identifies and communicates patient care trends and quality improvement opportunities to medical director, clinical manager, and staff.
• Participates in the resolution of unit‑based/patient‑related issues utilizing quality improvement techniques.
• Participates in the development, review, and revision of clinical pathways and standards of practice.

• Assesses learning needs of clinical personnel and provides feedback to Assistant Clinical Managers, Clinical Managers, Clinical Nurse Specialists, and/or the Center for Education and Development.
• Utilizes bedside teaching opportunities to facilitate the development of critical thinking skills of the clinical personnel.
• Incorporates the educator role into daily activities and facilitates the development of the interdisciplinary team members in the principles of care management.

• Acts as professional role model.
• Maintains knowledge of current standards of care via literature review and…