Manage a designated caseload to coordinate and complete timely assessment, planning, implementation and evaluation of discharge plans and care transitions across the continuum of care. Ensure optimum utilization of the patient’s and the Health System’s resources and perform these duties within the requirements of CMS and other external review agencies.
Duties and Responsibilities
Monitor daily census and assignment to assure all patients are assessed for case management needs including care coordination/transition and discharge planning, consultations, advocacy, education.
Maintain effective communication with health care team members related to assessment findings, discharge planning needs and provider orders needed to arrange Homecare, Durable Medical Equipment, Transportation, Skilled Nursing or Acute Rehab Facility placement, Substance Abuse Treatment and outpatient follow-up.
Maintain working knowledge of specific benefits and reimbursement guidelines, the discharge planning process and applicable federal, state and local regulations. Provide education and guidance on these topics to providers, patients and families as needed.
Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers.
Maintain timely documentation of assessment findings, discharge arrangements and actions taken according to departmental guidelines; prepare reports and maintain records as requested and/or required. Monitor daily census and assignment to assure all patients are assessed for case management needs including care coordination/transition and discharge planning, consultations, advocacy, education.
Maintain effective communication with health care team members related to assessment findings, discharge planning needs and provider orders needed to arrange Homecare, Durable Medical Equipment, Transportation, Skilled Nursing or Acute Rehab Facility placement, Substance Abuse Treatment and outpatient follow-up.
Maintain working knowledge of specific benefits and reimbursement guidelines, the discharge planning process and applicable federal, state and local regulations. Provide education and guidance on these topics to providers, patients and families as needed.
Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers.
Maintain timely documentation of assessment findings, discharge arrangements and actions taken according to departmental guidelines; prepare reports and maintain records as requested and/or required.
Inpatient Job Responsibilities/Activities
Complete initial assessment within 72 hours to identify psychosocial strengths, weaknesses, community living supports present and needed.
Contact with patient primary support systems to gather information regarding dynamics and needs of support system.
Conduct support system/family therapy to allow patient/support to practice skills needed to support community living and/or assist in development of functional patterns of interactions.
Conduct group sessions for patients focused on skill building/interactional skills.
Assist patient in development of safety plan to promote positive coping while living in community setting.
Facilitate discharge planning for patients, involving support systems when possible, to provide level of intervention that creates environment for crisis contacts and safe community living.
Interface with team to determine multidisciplinary assessment of discharge planning needs and provide information regarding support system/family function.
Update Interqual.
Other duties as assigned.
Typical case load is 10 patients.
