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JOB SUMMARY: Work with Registered Nurse Care Manager to provide timely and efficient identification of patients who need discharge planning.  Provide assessments of psychosocial impact of illness.  Provide direct services including discharge planning for patients needing community resources prior to discharge from the acute care setting.   ESSENTIAL FUNCTIONS:   - Plan of Care - Assesses, develops, impelemtn and monitors a comprehensive plan of care through an interdisciplinary team process in conjunction with the patient and family in internal and external settings. - Comprehensively assesses patient’s goals as well as their biophysical, psychosocial, environmental, and discharge planning needs and financial status. - Works collaboratively with RN Care Manager to develop appropriate discharge plan and ensure indicated referrals are completed in a timely manner. - Procures services and serves as advocate on behalf of patients and families for scarce resources. - Acts as a liaison to post hospital care provider and community health resources.   - Resources - Education patients, families, and medical staff regarding available resources and guidelines associated in accessing resources. Provide applications as needed for these resources. - Communicates Effectively - Resolves situations as appropriate within scope of job.  Handles complaints/concerns in a prompt and courteous manner; assess and directs to appropriate person to deal with concerns as needed; makes attempt to solve issues with involved parties. - Demonstrates tact, courtesy, sound judgment and a professional attitude when relating with patients, families, coworkers, physicians, and affiliated agencies. - Gives and receives feedback in a positive manner. - Communicates both verbally and in writing with physician and appropriate hospital staff regarding patient needs and progress of discharge plan. - Meets with Care Management Leadership to discuss case specific issues. - Actively participates in staff meetings, for information exchange, discussion of performance indicator results and action planning. - Develops professional relationship with community partners.   - Care Management Education -  Provides Care Management education to peers and consumers; participates in providing continuing educational activities. - Assist with providing education of Care Management services, policies and procedures to physicians. - Actively seeks to improve skills and knowledge base for personal and job development through literature review and participation in in-services and other educational programs. - Consistently works toward standards of excellence to continually improve personal performance. - Responsible for ensuring current licensure, Basic Life Support (BLS) certification, and other required certification as applicable. - Responsible for documenting continuing education and mandatory in-service attendance and forwarding the information Care Management Leadership.   - Professional Public Image - Portrays a positive public image at all times. - Acts as a role model for others. - Recognizes, appreciates, accepts and values differences in people and treats all with dignity and respect. - Attends and participates in CHI- St. Vincent facility committees as assigned. - Wears clothing and CHI-St. Vincent identification badge consistent with dress code and attends to personal hygiene to maintain a clean, well groomed appearance. - Maintains attractive, safe, and clean workspace. - Meets CHI- St. Vincent facility attendance standards.       - Team Work - Builds and maintains positive relationships with healthcare team, placing organizational/team goals first. - Assumes responsibility, authority, and accountability for patient load, assisting other coworkers when requested or as the need arises. - Meets deadlines and takes responsibility for accomplishing one’s own work. - Takes feedback from coworkers and uses feedback to improve performance. - Participates in peer evaluations. - Identifies and actively participates in projects to assist with team self actualization. - Participates as a team member with department wide events/programs. - Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner.   - Technology - Documents data accurately in the utilization management module to ensure data for tracking and trending is accurate. - Uses technology for risk management, quality improvement activities, data collection, process improvement and evaluation of improvement interventions. - Maintains technical knowledge and skills of computer systems (Interqual, Cerner, Star, and Email)   - Organizational Skills - Consistently makes appropriate mandatory reports to appropriate agencies.   - Other Duties as Assigned  
Job ID
2020-126630
Department
Case Management
Facility
CHI St. Vincent Health
Shift
Day
Employment Type
Full Time
Location
AR-LITTLE ROCK
Full Time, 7a-7p, Saint Joseph Main Hospital, Case Management
Job ID
2020-129847
Department
Case Management
Facility
CHI Saint Joseph Hospital
Shift
Day
Employment Type
Full Time
Location
KY-LEXINGTON
Full Time, Day Shift, Saint Joseph East Hospital, Case Management
Job ID
2020-129845
Department
Case Management
Facility
CHI Saint Joseph East
Shift
Day
Employment Type
Full Time
Location
KY-LEXINGTON
As a Case Manager with CHI you will coordinate patient care between patients, caregivers, and the multidisciplinary team; collect and evaluate information to facilitate care by assuring that admissions, continued stays, and ancillary services are medically necessary, cost-effective, and providing the appropriate setting to qualify for reimbursement.  The case manager intervenes when necessary to assure that care is coordinated and timely. Come join our Care Management team today! CaseManagerTexas
Job ID
2020-128359
Department
Case Management
Facility
CHI St. Luke's Health - The Vintage Hospital
Shift
Varied
Employment Type
Part Time
Location
TX-HOUSTON
As a Case Manager with CHI you will coordinate patient care between patients, caregivers, and the multidisciplinary team; collect and evaluate information to facilitate care by assuring that admissions, continued stays, and ancillary services are medically necessary, cost-effective, and providing the appropriate setting to qualify for reimbursement.  The case manager intervenes when necessary to assure that care is coordinated and timely. Come join our Care Management team today! CaseManagerTexas
Job ID
2020-128358
Department
Case Management
Facility
CHI St. Luke's Health - The Vintage Hospital
Shift
Varied
Employment Type
Part Time
Location
TX-HOUSTON
As a Case Manager with CHI you will coordinate patient care between patients, caregivers, and the multidisciplinary team; collect and evaluate information to facilitate care by assuring that admissions, continued stays, and ancillary services are medically necessary, cost-effective, and providing the appropriate setting to qualify for reimbursement.  The case manager intervenes when necessary to assure that care is coordinated and timely. Come join our Care Management team today!   CaseManagerTexas
Job ID
2020-128357
Department
Case Management
Facility
CHI St. Luke's Health - The Vintage Hospital
Shift
Varied
Employment Type
Part Time
Location
TX-HOUSTON
As a Case Manager with CHI you will coordinate patient care between patients, caregivers, and the multidisciplinary team; collect and evaluate information to facilitate care by assuring that admissions, continued stays, and ancillary services are medically necessary, cost-effective, and providing the appropriate setting to qualify for reimbursement.  The case manager intervenes when necessary to assure that care is coordinated and timely. Come join our Care Management team today!   CaseManagerTexas
Job ID
2020-123787
Department
Case Management
Facility
CHI St. Joseph Health Regional Hospital
Shift
Day
Employment Type
Full Time
Location
TX-BRYAN
What you will do: - Assists in the identification of member populations needing care coordination and social work intervention. - Acts as a liaison with patients and families to physicians, clinical staff, community resources and others. - Conducts a psychosocial assessment and acts as a patient’s advocate, by responding to and working with patients to address needs and resolve their concerns. - Provides Health Promotion activities and education for patients. - Functions as an active team member by effectively collaborating, communicating and coordinating among all responsible parties of an individual patient’s multidisciplinary health care team striving to eliminate fragmentation, duplication or gaps in health care. - Optimizes patient and family independence and self determination by providing education and health coaching, and assisting with improving problem solving and coping skills as needed.  - Works with patients, families, and caregivers in the primary care and specialty clinics to address barriers that may be affecting the patient’s health, including, economic needs, behavioral issues, services in home, disability, out of home placement - Identifies and links families to community resources. - Other duties as assigned within Population Health Care Management  
Job ID
2020-119323
Department
Social Work Services
Facility
CHI Health Clinic
Shift
Day
Employment Type
Full Time
Location
NE-OMAHA
Job Summary/Job Purpose Provides general clerical support to a specific unit including receptionist duties, transcription, filing and processing of physician orders; and coordination of unit communication with hospital departments as well as the public. Also, provides direct patient care under the supervision of the licensed nursing staff within the scope of practice. Contributes to the safe and efficient operations of nursing service. Essential Functions • Communicates effectively and appropriately • Contributes to maintenance of clean, safe environment to minimize hazards of infection or injury to patients and/or staff. • Obtains basic physical assessment data (vital signs, intake/output, weights etc.) and documents in patient medical record. • Provides routine and procedural hygienic needs to patients. • Assist in meeting patient’s activity needs to include: elimination, comfort and privacy by responding to patient’s request. • Assist with performance of PT needs under the assistance of RN/PT to include range of motion, ambulation, transfers, ADL training for home care. • Demonstrates competency in unit protocols for performing EKG’s(if applicable), glucose monitoring, and other competencies based on department discretion. • Demonstrates knowledge related to age appropriate behavior of pediatrics, adolescents, adults and geriatrics as applicable. • Documents or reports care provided, observations, and pertinent information to the nursing services. • Assist in prevention of nosocomial infections as evidenced by adherence to infection control policies and procedures. • Uses personal protective equipment and complies with all universal precautions, bloodborne pathogens and specific isolation precautions (e.g. contact, airborne, protective). • Completes patient care assignments by the end of the shift or reports status of care to charge nurse. • Make rounds on patients hourly. • Responds to requests promptly and courteously • Attends all mandatory hospital-based in services on time. • Assist with orientation of new unit personnel according to unit protocol. • Attends 80% of shift meetings, reads and initials all meeting minutes. • Completes all core and unit specific competencies on time. • Assists in delivering high quality health care services in a professional, compassionate, and courteous manner while respecting the dignity and individuality of each person who comes in contact with the organization by following the standards of excellence, standards of behavior, and the standards of professional appearance and conduct - Other duties as assigned  
Job ID
2020-128617
Department
ICU/Med Surg
Facility
CHI Flaget Memorial Hospital
Shift
Night
Employment Type
Full Time
Location
KY-BARDSTOWN
JOB SUMMARY / PURPOSE The Director of Care Management is responsible for the oversight of Care Management and Social Services, including but not limited to clinical resource management, discharge planning activities, patient advocacy, clinical social work and best practice in medical necessity determination and concurrent review. ESSENTIAL KEY JOB RESPONSIBILITIES 1. The Director is responsible for the overall direction and management of these areas, including planning, organizing and directing all activities, staffing, performance improvement in the delivery of clinical services (such as LOS reduction), and reporting needs within the medical center and CHI Health, as well as government and regulatory reporting. 2. The Director guides Care Management activities according to the needs, requirements, and policies of the medical center, the affiliated medical groups and health plans, CHI Health, any Federal and State agencies, and according to standard practices of the professions under the director's accountability. 3. The Director will consult and collaborate with other managers, physicians, administration, and community based healthcare workers regarding care management issues identified through corporate or facility initiatives and current literature. 4. This position will work closely with all departments at the medical center and the post-acute service providers to streamline the patient transition through the health care system and into the community post discharge. 5. The Director participates regularly in medical center, division, or corporate meetings pertinent to the accountable areas, and also participates in corporate strategic planning and performance improvement teams and programs as necessary. 6. This position requires the full understanding and active participation in fulfilling the Mission of the Organization. It is expected the director will demonstrate behavior consistent with the Core Values of the organization. The director will support the Organization's strategic plan and the goals and direction of the Performance Improvement Plan (PIP). 7. This position considers the population served by the medical center and area clinical integration programs and leads efforts to optimize care coordination across the care continuum. This coordination ensures a plan of care for patients in all stages of health needs. 8. Other duties as assigned. Registered Nurse, RN, LCSW, Social Worker, Case Management, CM, CCM, Care Management, Care Coordinantion, Manager, Director ~DH-LI~ #CCLeaderNE #NurseLeader #RN
Job ID
2020-112487
Department
Care Management
Facility
CHI Health Creighton University - Bergan Mercy
Shift
Day
Employment Type
Full Time
Location
NE-OMAHA
Job Summary:   This job is responsible for working with members, providers and multi-disciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential.  Work is conducted in accordance with professional clinical standards and applicable accreditation/regulatory requirements.  An incumbent maintains an ongoing member caseload for regular management and outreach, and work is strongly focused on ensuring that members are on track to progress towards desired outcomes based on quality care that is medically-appropriate and cost-effective based on the severity of illness and the site of service.  Care coordination is provided primarily through telephonic communication, home visits and/or direct face-to-face contact, and an incumbent uses motivational interview and clinical guideposts to educate, motivate and support change during member contacts.  Local travel (up to 40%) may be required, depending on the complexity level of assigned member cases. Work also includes: 1) completing clinical assessments and determining qualification for case management services; 2) developing, implementing, modifying and monitoring a case management plan to address member needs and goals; 3) documenting services provided in accordance with established guidelines; and 4) coordinating integrated outpatient care, including assessing barriers to care and identifying community resources and specific wellness programs (e.g. asthma, depression disease management) appropriate to enhance the continuity of care for members.  Work requires understanding of psychosocial and clinical education concepts, professional standards and accepted guidelines for patient care, community resources and applicable regulatory requirements.  Knowledge of transitional case management concepts, methodologies and tools is also required.  An incumbent uses the plan of care in giving members the tools they need to assist them in taking charge of their medical/psychosocial conditions to improve their overall health and quality of life, and to decrease the potential for hospital admissions/readmissions.   This supports the Pierce County Region.   Essential Duties: Completes member screening within scope of experience, training, and expertise, and communicates social, emotional and patient/family stressors to interdisciplinary healthcare provider team as relates to member’s plan of care. Coordinates with the member/family, the interdisciplinary healthcare provider team, insurance payers and community resources in organizing the outpatient care; promotes and facilitates effective chronic disease self-management and provides tools to assist members/families in achieving maximum levels of wellness and independence. Serves as a member of the provider/interdisciplinary team and contributes to the development/modification of a comprehensive plan of care for assigned caseload of at-risk patients. Monitors member’s progress towards achievement of self-management goals identified in the plan of care and provides ongoing status reports to management, provider team and/or other interested parties. Documents services provided in accordance with Care Management Documentation Standards and actions taken in the medical record in a timely and comprehensive manner that reflects recognition of the legal significance of an accurate and complete record. Researches and identifies community resources, vendors, medical supply companies, healthcare agencies and other resources appropriate to the patient’s individualized plan of care. Additional Responsibilities: Adheres to and exhibits our Core Values of Reverence, Integrity, Compassion and Excellence.
Job ID
2020-119182
Department
Home Health
Facility
CHI Franciscan St. Joseph Medical Center
Shift
Day
Employment Type
Full Time
Location
WA-TACOMA
GENERAL SUMMARY: Supports the educational and treatment related initiatives of House of Mercy’s adult programs. Primarily serves as a teacher, coach, mentor, and role model to adult resident’s and their children. Supports clients through the provision of education and treatment supports in connection with identified clinical initiatives and interventions in the areas of: chemical dependency; daily living skills; parenting; self-sufficiency; behavioral/mental health; and, relationships. Provides behavioral health intervention services to identified children and adults.     ESSENTIAL FUNCTIONS: - Establishes rapport and develops a therapeutic relationship with assigned clients. Consistently maintains and employs a therapeutic perspective/approach when dealing with clients, their children, visitors and staff. Maintains appropriate professional boundaries avoiding dual relationships. - Participates in the admission process for all adult halfway house/residential care program residents utilizing a warm, compassionate and empathic manner to ensure that they feel welcome, appreciated, and understood. Orients new residents to program guidelines and expectations. - Observes resident interactions, appropriately intervenes when behaviors are not consistent with expectations, and teaches/coaches/role models conflict resolution/problem-solving skills as a means for effectively managing differences. - Facilitates Life Skills groups teaching essential skills necessary for independent living. On a daily basis models and mentors residents and their children on basic living tasks. - Provides education and treatment supports in connection with identified clinical initiatives and interventions in the areas of: substance use disorders; daily living skills; parenting; self-sufficiency; behavioral/mental health; and, relationships. - Consults and reviews complex situations with the treatment team as they occur. Utilizes knowledge/skills of intervention approaches/strategies to deal with children who are presenting behavioral challenges. - Provides behavioral health intervention services to identified children and adults consistently documenting interventions in conformance with House of Mercy and Medicaid services expectations. - Assures appropriate and timely administration of medications for clients and children. - Performs Breathalyzer Tests and collects urinalysis specimens for toxicology screens from residents adhering to House of Mercy Chain of Custody guidelines and procedures. - Performs daily reviews of resident living areas to insure safety, cleanliness, and organization of personal items and notifies appropriate program personnel of ongoing issues/trends. Teachers, coaches, and mentors residents in developing skills necessary to meet these expectations. - Transports residents and their children as assigned. Assists child care and parenting staff with transportation and supervision of residents and their children during recreational and educational outings. - Provides accurate information on a client’s behavior and progress for use in treatment plan review and other case management meetings. Collaborates with other treatment team members in carrying out treatment plans. Initiates corrective action with residents who are not following treatment plan goals.
Job ID
2020-131118
Department
Treatment Center
Facility
MercyOne Des Moines Medical Center
Shift
Varied
Employment Type
Per Diem
Location
IA-DES MOINES
Job ID
2020-124429
Department
Treatment Center
Facility
MercyOne Des Moines Medical Center
Shift
Varied
Employment Type
Part Time
Location
IA-DES MOINES
Is responsible to assist in the implementation, provision and coordination of social services offered to patients in the medical center.  All the criteria-based duties and standards within this document will be performed according to the department and hospital wide policies, procedures, and guidelines.   Essential Key Job Responsibilities - Coordinates and directs social services to ensure patient needs are met. - Interacts professionally with patient/family and involves them in formation of Plan of Care - Participates in psychosocial identification and planning for complex/high risk patients - Assesses, counsels, refers and coordinates intervention relating to cases of abuse, neglect, exploitation of children, vulnerable adults, domestic violence or sexual assault. - Identifies resources needed and works with the necessary agencies to assist patient/family with application, referrals, etc. - Responsible for participating in multi-disciplinary discharge planning team meetings to assess and arrange discharge needs or alternate level of care. - Completes brief assessments on complex situations and patients needing extensive social work intervention.
Job ID
2020-129185
Department
Social Work Services
Facility
CHI St. Alexius Bismarck
Shift
Varied
Employment Type
Part Time
Location
ND-Bismarck
Is responsible to assist in the implementation, provision and coordination of social services offered to patients in the medical center.  All the criteria-based duties and standards within this document will be performed according to the department and hospital wide policies, procedures, and guidelines.   Essential Key Job Responsibilities - Coordinates and directs social services to ensure patient needs are met. - Interacts professionally with patient/family and involves them in formation of Plan of Care - Participates in psychosocial identification and planning for complex/high risk patients - Assesses, counsels, refers and coordinates intervention relating to cases of abuse, neglect, exploitation of children, vulnerable adults, domestic violence or sexual assault. - Identifies resources needed and works with the necessary agencies to assist patient/family with application, referrals, etc. - Responsible for participating in multi-disciplinary discharge planning team meetings to assess and arrange discharge needs or alternate level of care. - Completes brief assessments on complex situations and patients needing extensive social work intervention.
Job ID
2020-129183
Department
Social Work Services
Facility
CHI St. Alexius Bismarck
Shift
Varied
Employment Type
Full Time
Location
ND-Bismarck
Is responsible to assist in the implementation, provision and coordination of social services offered to patients in all patient areas but specifically to units that require MSW license such as Psychiatry and KDU. All the criteria-based duties and standards within this document will be performed according to department and hospital wide policies, procedures and guidelines. Essential Key Job Responsibilities - Coordinates and directs social services to ensure patient needs are met. - Interacts professionally with patient/family and involves them in formation of Plan of Care - Provides “options to potential dialysis patients prior to the initiation of dialysis and completes the HCFA 2728 - Completes a psychosocial assessment and re-assessment on patients. Develops specific measurable and realistic plans and objectives. - Provides support and counseling to patient/families experiencing and /or anticipating issues of adjusting to an illness, catastrophic event or diagnosis, change in living situation, end of life issues, grief and loss. - Assesses, counsels, refers and coordinates intervention relating to cases of suspected abuse /neglect or exploitation of children, vulnerable adults, domestic violence or sexual assault. Responsible for participation in multi-disciplinary discharge planning team meetings to assess and arrange discharge needs or alternate level of care.
Job ID
2020-114854
Department
Social Work Services
Facility
CHI St. Alexius Bismarck
Shift
Varied
Employment Type
Full Time
Location
ND-Bismarck
Your work should be more than just a job. If you are looking for career development, flexibility in your schedule and work-life balance, your journey begins here!   We are looking for a PRN Medical Social Worker to join our growing team! This position will be seeing patients in Kitsap and Pierce Counties.  - Provides resources and education to patients and their caregivers - Participates in the coordination of services with other disciplines and community resources as needed - Evaluates and revises care plans/assessments based on changes in patients and/or their environments - Participates in regular case conferences and in-services or special case orientations as needed
Job ID
2020-125334
Department
Home Health and Hospice
Facility
CHI Franciscan Health at Home
Shift
Day
Employment Type
Per Diem
Location
WA-University Place
Franciscan Medical Group is currently seeking a full time Bahavioral Health Specialist for our Franciscan Center for Mental Health Clinic covering Kitsap and Mason county Primary Care locations. Our desire is to provide integrated behavioral health services in our primary care clinics while implementing the UW AIMS Collaborate Care service model. This opportuntiy will allow you to work with our Psychiatrists and other MSW professionals in primary care and NW Washington Family Medicine Residency training program. Be on the cutting edge of behavioral health integration in primary care! Fixed hours with weekends and organizationally recognized holidays off.    Job Summary: This job is responsible for coordinating and supporting mental health care with the assigned clinic(s) and for coordinating referrals to clinically-indicated services outside the clinic. An incumbent functions as a core member of a Collaborative Care team that is made up of the patient’s primary care provider, a psychiatric consultant and, when available, other providers in the primary care clinic. An incumbent may provide evidence-based treatments or consult with other mental health providers when such treatment is indicated.   Essential Duties: - Performs patient assessment/data collection, interprets findings and formulates treatment plans. - Implements and updates psychosocial plan of care and treatment based on patient needs throughout patient’s course of care. - Works with treatment team to provide and manage treatment. - Provides effective psychotherapy and brief interventions within scope of practice Identifies and implements strategies to meet the educational needs of the patient/family/significant others as relates to psychological health and/or substance use. - Designs effective curricula for education to address psychosocial/behavioral health issues in primary care and leads effective classes for staff/medical practitioners and other behavioral health providers. - Completes all required documentation, in an accurate and thorough manner, in accordance with CHI-FH and/or grant documentation standards. - Monitors the site’s behavioral health capabilities, identifying issues related to patient services and makes recommendations for improvement. - Cultural Sensitivity and Competence: Demonstrates proper use of communication tools/materials for effective communication and understands how the culture(s) of patient populations can affect communication, collaboration and the provision of care, treatment and services. Patient Population Served: Demonstrates knowledge and proper skills associated with the department’s defined specific populations served. - Adheres to and exhibits our Core Values of Reverence, Integrity, Compassion and Excellence.
Job ID
2020-115072
Department
Behavioral Health
Facility
CHI Franciscan Medical Group
Shift
Day
Employment Type
Full Time
Location
WA-SILVERDALE
Case Management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet a patient’s health needs and promoting quality cost-effective outcomes. The goal of care coordination is to help patients achieve optimal health, gain access to services and manage the appropriate utilization of internal resources, balanced with patient’s rights to self-determination. Essential Key Job Responsibilities - Coordinates discharge plans for patients - Identifies complex discharge planning needs - Manages the use of internal resources for patients plan of care - Facilitates discharge to next level of care ( TCU, Rehab, Long Term Acute Care ) - Participate in daily discharge team meetings - Interacts professionally with patient/family/physicians and other disciplines and involved them in formation of plan of care. #carecoordination
Job ID
2020-121066
Department
Case Management
Facility
CHI St. Alexius Bismarck
Shift
Varied
Employment Type
Part Time
Location
ND-Bismarck
POSITION SUMMARY: The RN Utilization Review works with the Care Coordination team to facilitate patient care during their hospital stay. The Case Manager will work closely with the providers to ensure proper care for a safe transition at discharge.   ESSENTIAL JOB FUNCTIONS: - Assists Utilization Review and negotiates lengths of stay and transitional plans with relevant others. - Conducts admission review per the Utilization Management Plan to ensure that the hospitalization is warranted based on established criteria. Reviewing may be both concurrent or post discharge. - Applies Milliman Careguidelines Criteria for appropriate status determination and accurate level of care. - Engages in discussion with the attending provider for clarification and/or status correction. - Ensures timely communication with Case Management staff for all concurrent status changes. - Administers Notice of Status Change to the patient/family when indicated. Provides education and information for the patient/family for clarification of the change. - Ensures timely notification to admitting status of change or status discrepancies identified. - Monitors insurance coverage for patients. - Provides clinical information as requested from the insurance payer via telephone or fax in a timely manner to prevent technical denials. - Enters authorization, approvals and denials into electronic medical records. - Engages the attending provider to advocate and communicate via peer to peer review for discussion with insurance for admission, continued stay or status when required. - Collaborates in monitoring and addressing observation outliers and status discrepancies with medical records department and admitting department. - 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. - Assist with follow up appointments or completes list of discharged patients for unit secretary to make appointments. - Identifies high-risk/complex patients for ongoing case management. - Interacts with patients, families, physicians, and other health team members to develop proactive plans for continued care. - Evaluates and modifies plans according to changing patient needs and clinical data; documents and communicates plan to all team members. - Intervenes when medical complexity results in fragmented care. - Identifies and acts to eliminate gaps in clinical care; makes referrals in collaboration with discharge planning as indicated. - Facilitates the multidisciplinary team rounds to identify patient’s needs up discharge and to establish an effective plan of care to meet the patient’s continuum of care needs. - Rounds and works closely with providers to ensure appropriate care is being provided. - Completes discharge phone calls to patients discharged home. - Consults clinicians, other departments, and committees as needed to support the patient through the care continuum. - Collaborates with appropriate staff and management to facilitate the development of case management tools, i.e. pathways and protocols, clinical indicators that demonstrate best practice and disease state management processes. - Swing bed Activities program coordinator to ensure guidelines are being met set by CMS. - Leads community coalition meeting - Attends Joint Success twice a month to anticipate discharge needs of orthopedic patients. - Assist patients with any discharge needs (Nursing Home, SNF Placement, Hospice Referrals, Home Health Referrals, Home Infusion, Wound Care, and DME setup). - Facilitates insurance denials and Peer to Peer process. - Adheres to standards of care set by the department. - Demonstrates professional judgment concerning patient care delivery - Demonstrates ability to establish priorities and organize effectively. - Assumes responsibility for professional growth and continuing education. - Attends 85% of department meetings/in-services. - Demonstrates professional written and verbal skills. - Demonstrates professional attitude and interest in work by maintaining acceptable work habits and behavior. - Assumes advocate role for patients as a liaison between the patient/family and physicians, the hospital, insurers, community resources and others. - Demonstrates ability to maintain professional demeanor in stressful situations. - Demonstrates commitment to customer service. - Demonstrates ability to work effectively in a multi-disciplinary team. - Demonstrates ability to communicate professionally and assertively with a variety of customers including but not limited to, physicians, patients and families, co-workers and insurers.
Job ID
2020-131281
Department
Care Coordination
Facility
MercyOne Newton
Shift
Day
Employment Type
Full Time
Location
IA-NEWTON

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