Care Manager

The Care Manager works collaboratively with interdisciplinary and healthcare team members, both internal and external to the organization, to facilitate patient care through effective utilization and monitoring of healthcare resources. The Care Manager assumes a leadership role to achieve safe discharge planning along with desired clinical and financial outcomes, coordinating care and services through the acute care episode and across the continuum.

• Completes a face‑to‑face assessment of all new patients in caseload within 24 hours or next business day to identify appropriateness for acute care, level of care and to anticipate high‑level care planning needs.
• Screen high‑risk patients with Lace score ≥10 to reduce 30‑day readmissions.
• Consults with attending physicians regarding potential care transition barriers identified as a result of this process.
• Assumes transition process in collaboration with the multidisciplinary team and patient/family and assists with executing the plans and interventions to facilitate the stay and manage the length of stay.
• Facilitates patient care conferences/complex case conferences proactively as needs are identified to reduce avoidable readmissions.

• Provides an Important Message notice and choice on Medicare patients as appropriate.
• Identifies and reports process improvement opportunities by capturing delays in care and documenting avoidable days in MIDAS per guidelines.
• Monitors and facilitates appropriateness of tests/procedures, consultation, treatment plans and resource utilization.

• Collaborates with social workers for patients with complex, clinical, financial and psycho‑social needs.
• Reviews physician orders and patient progression on a daily basis and intervenes with care coordination as needed; collaborates with other departments to eliminate barriers when necessary.
• Actively participates in multidisciplinary rounds, long stay rounds, and meetings that promote comprehensive and coordinated care plans and monitor progress against goals.
• Provides clear and timely information on the patient’s plan of care to the next provider.
• Builds trusting relationships with attending physicians, patients/families, and other members of the healthcare team; maintains contact to ensure the most cost‑effective plan of care is carried out and appropriate in‑network providers are utilized.
• Establishes a caring relationship with patients and their caregivers, promotes patient engagement and guides patients/families through the transition phase.
• Establishes a comprehensive care transition plan, organizes, secures, integrates and modifies resources necessary to meet assessment plan goals.
• Documents plan of care and updates/changes in the electronic medical record.
• Arranges home care, DME, infusion and/or post‑acute services with the social worker; maintains good working relationships with community providers.
• Assists with medication issues for patients as needed.
• Obtains legal guardianship, competency determinations, adoption‑related situations, and all cases where adult or child abuse is a concern; ensures all legal documents are completed.
• Provides counseling and support as needed; identifies cases that would benefit from palliative care and elicits palliative consults.

• Serves as a resource to patients, physicians, administration, and other disciplines regarding care management functions and expertise.
• Participates in defining, maintaining, and interpreting care management standards of practice.
• Assesses and educates patients and families on community agencies and resources.
• Educates and reinforces early identification of changes in patient condition and changes in care transition plans.
• Assumes responsibility for own professional growth and shares knowledge with coworkers and other health care providers.
• Performs assigned work safely, adhering to established departmental safety standards rules and practices; reports any unsafe activities or conditions to supervisor in a timely manner.

• Maintains performance, patient, and employee satisfaction and financial standards as…