Case Management Special Programs - Per Diem Case Manager

SUMMARY:

The Case Management Special Programs - Per Diem Case Manager reports to the Manager of Case Management Special Programs or Director of Case Management. Provides staffing support to the various programs included in the Case Management Special Programs department including Surgical Services Case Management, Outpatient High Risk Case Management, and Transfer and Access Case Management. The Per Diem Case Manager will receive training for the following programs and may be asked to participate in the various programs.

Surgical Services Case Management
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Provides coordinated care support to the Surgical Services, Total Joint Center, Case Management, and the Clinical Manager(s) of respective services across the Brown University Health system. The Surgical Services Case Manager reviews patients for potential post-acute needs, conducts interview prior to their scheduled surgery, and assists with coordination of care at the various hospitals throughout Brown University Health.

Collaborates with the clinical healthcare team across the patient care continuum to include pre-operative service coordination and post hospital discharge follow-up. Participates in the oversight of the progress of a specific patient population. Collects data and facilitates clinical quality improvement (CQI) teams to enhance the quality and cost effectiveness of patient care and prevent readmissions.

Outpatient High Risk Case Management: Collaborates with the clinical healthcare team across the patient care continuum and participates in the oversight of the progress of complex patients. The Outpatient High Risk Case Manager will work with patients enrolled in the BUH Mobile Integrated Health Program as well as others referred from various settings throughout Brown University Health system. When applicable, they will collaborate with the inpatient case management team to provide a smooth transition post-acute discharge.

They will meet with the patients in the community as needed and help the patients collaborate with community providers to maximize their support and resources outside of the hospital. Collects data and facilitates clinical quality improvement (CQI) to enhance the quality and cost effectiveness of patient care and prevent readmissions.

Transfer and Access Case Management
:
The Transfer and Access Case Manager will have an opportunity to work with a multidisciplinary team across the Brown University Health system to assist with capacity management and will play a lead role in repatriation. The Nurse Transfer and Access Case Manager will be highly effective in clinical fact gathering and analysis to facilitate appropriate pathways to optimize capacity. The Transfer and Access Case Manager will coordinate closely with the Capacity Management and Access center team, Case Management Team, physician administrator on call, and with staff at non-Brown University Health organizations to ensure timely access to care and efficiency in patient flow.

Transfer and Access Case Manager will collaborate with the clinical healthcare team across the patient care continuum and participates in the escalation of complex patients to case management leadership.

Discharge Review Specialist: Collaborates with SNF committee team and care team members to evaluate post-acute discharge planning needs. Reviews the initial patient discharge plan and reviews with patient, family members and other members of the interdisciplinary team. Reassesses the discharge as needed.

Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these guide our everyday actions with patients, customers and one another.

The Case Manager will collaborate with various departments and programs to coordinate appropriate services for patients.

Surgical Services Case Management: Completes initial Case Management Assessment for surgical patients prior to their planned procedures. Sets expectations for anticipated discharge home after surgery and arranged for post-acute care as indicated.

Outpatient High Risk Case Manager: Follows patients enrolled in the Mobile Integrated Health Program and other identified patients with high risk for readmission to the hospital. Works with patients and community providers to facilitate obtain resources in the community as needed.

Transfer and Access Case Management: Works closely with the Transfer and Access team to identify and coordinate transfers into the BUH hospital system and obtains repatriation agreements as necessary. Helps to facilitate transfers within the hospital system to accommodate for increased patient census and improve patient flow.

Discharge Review Specialist: Partners with medical staff and other members of the healthcare team in collaboration with the patient/family to facilitate the plan of care for a defined patient population across the continuum of care. Identifies a high-risk patient population…