Central Case Manager

POSITION SUMMARY

The Central Case Manager will be collaborating with the assigned facilities and the Interdisciplinary team to come up with an individualized plan of care, to ensure patients progress and safely discharge the patient back to the community or to a Long Term Care setting.

DUTIES AND RESPONSIBILITIES

• Demonstrates commitment to company's mission, values and standards of ethical behavior.
• Models a positive and professional image that emulates the organization's mission and encourages a spirit of cooperation with co-workers. Provides assistance to co-workers and promotes teamwork by sharing information useful to achieving desired results.
• Ensures that all residents are treated fairly, with kindness, dignity, and respect, and their rights are protected at all times.
• Respects and upholds all residents' personal and property rights whenever carrying out duties, including knocking before entering a resident's room.
• Complies with all company and departmental policies and procedures.
• Monitors the care plans to ensure the effectiveness and appropriateness and in patient services; ensure the appropriate care is being provided and meet the needs of the patient until discharge.,
• Meet and Greet with the new admissions patient
• Attends morning Stand-Up meetings and afternoon Stand-Down Meetings.
• Monitor patients' progress towards achievement and periodically reassess changes in health status.
• Review patients' medications and treatments prior to admissions, to identify high cost medications and treatments.
• Respects patient rights and personal property.
• Identify and develop new community resources.
• Assist with problem solving in coordination with Social Services.
• Works closely with the Rehabilitation Team to ensure the patient is getting the services needed.
• Collabrates with the DOR in managing patients' minutes as authorized by the HMO plans.
• Identifies any barriers during the patient's rehabilitation, and addresses the departments involved, to ensure patient's progress in rehab.
• Communicates with the HMO case managers and gives updates on patients' progress in the skilled services provided.
• Chart observations - Ensure they are done properly and accurately.
• Other data review, related to the clinical data of the patient.
• Conducts PPS weekly meetings (HMO)
• Attends triple check meetings (HMO)
• Conducts care plan meetings (within 72 hours upon admission, weekly, and monthly depending on the patient's case)
• Conducts IDT meetings (14 days upon admission)
• Conducts RNA meetings with the DOR and RNA staff to identify patients that may need skilled services to improve the quality of life.
• Help reduce avoidable hospital admissions and A.M.A. (tracking and identifying the cause of hospital readmissions and A.M.A. in coordination with the DON
• Improve providers and members satisfaction during patient's time in the facility.
• Identify the patient's barriers in progress and address the patient's grievances to the departments involved, and collaborate to resolve the issues.
• Make sure authorizations for skilled services are in place and updated - the case manager specialist will send clinical notes and requests for extending skilled authorizations as needed, and upload it to PCC
• Follow up for any changes in condition, new medications ordered, and doctor appointments (72 hours post discharge, weekly, and monthly).
• Interprets department policies and procedures to personnel, residents, visitors, family members, etc., as necessary.
• May perform day-to-day departmental duties as needed.
• Performs other related duties as required.

The above listing of duties and responsibilities is not intended to be all-inclusive but rather to serve as a description of the range of duties and general nature of the position. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

KNOWLEDGE, SKILLS, ABILITIES & QUALIFICATIONS