Develops, coordinates and oversees the implementation of patient specific plan of care. Works collaboratively with physicians, staff, and other health care professionals/agencies to negotiate care coordination across the health care continuum for disease specific populations. Communicates feedback about progress towards client goals with appropriate individual/groups at specific intervals. Collaborates with other services and disciplines, and when appropriate, the client’s medical physician and/or related health care professionals/agencies to enhance a holistic approach to patient care. Ensures safety, best practice, and high quality standards of care are maintained across the continuum. Is accountable for Care Management evaluation including: data capture and analysis, outcome achievement, and fiscal responsibility in an effort to improve service, quality and cost provided to the clients served.
- Completes a comprehensive assessment of the client’s holistic health status and needs to include clinical condition, support systems and resources, client/family knowledge, perception and adjustment towards disease process, and community resources.
- Screens patients/clients for identified and potential needs. Makes referral to appropriate multi-disciplinary services.
- Documents case management plan to include: assessment, client/family participation and understanding, consult referrals and discharge plan of care.
- Educates staff, clients/families, and medical community on care coordination and regulatory issues that impact care and outcomes.
- Documents clearly and timely in the Electronic Health Record and other required systems to insure effective communications along the continuum.
- Collaborates with Utilization Management staff regarding payer information, level of care and status determinations for patients.
- Understands and self manages to support facility/CIN level success goals; including improvements in quality, cost of care and member experience for the facility/CIN’s population.
- Identifies opportunities for improvement (at individual, facility/CIN levels and actively works with healthcare and facility/CIN team to correct or improve results.
- Develops and utilizes tools available to effectively evaluate, summarize and communicate patient’s progress toward outcomes to members of the healthcare team and patient and family.
- Has a working knowledge of financial and reimbursement processes Medicare DRG payment, Case Rates, Managed Care Risk Contracting, etc.
- Coordinates and conducts patient care rounds and family conferences.
- Collaborates with Unit Director in strategies/tactics to achieve unit based goals such as quality, financial, and safety indicators.
- Demonstrates a wide theory/research base that supports sound clinical and psychological orientation. Specific knowledge regarding pathophysiology, natural history of disease processes, and impact on functional ability and level of care.
- Serves as a professional role model/mentor and change agent to develop and assist others.
- Other duties as assigned by CIN Director/Care Management/Social Services Manager.