Case Manager, Sr. coordinates the overall interdisciplinary plan of care for patients, from admission to discharge. Monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers. Being a Case Manager, Sr. evaluates the needs of the patient, the resources available, and recommends and facilitates the plan for the best outcome. Develops a discharge plan that provides the best available resources to meet ongoing patient needs and that encourages compliance with medical advice. Additionally, Case Manager, Sr. identifies patient care issues and suggests revisions to or new clinical pathways to improve quality of care. May also be responsible for conducting utilization reviews. Typically requires a bachelor's degree of Nursing. Typically reports to a head of a department/unit. Requires Registered Nurse (RN). The Case Manager, Sr. contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. To be a Case Manager, Sr. typically requires 4 to 7 years of related experience. (Copyright 2024 Salary.com)
Counselor/Social Worker/Psychology Graduate/Case Manager
SUMMARY:
Provides support for designated clients/beneficiaries which includes coordinating an array of services designed to improve the health of high needs, high risk clients/beneficiaries. Care coordination responsibilities will include assessment, care planning and monitoring of client status, and implementation and coordination of services. Provides support to clients/beneficiaries for effective care transitions, improved self-management skills and enhanced client/beneficiary-provider communication. Will facilitate interdisciplinary consultation, collaboration and care continuity across care settings.
ESSENTIAL FUNCTIONS:
· Engages clients in care coordination activities designed to promote improved utilization of health care services, including the creation and ongoing maintenance of a patient-centered, goal oriented Health Action Plan (HAP).
· Assesses activation level for self-care through use of the Patient Activation Measure® (PAM®).
· Provides evidence-based health assessments and screenings such as; BMI, PHQ-9, Katz ADL, GAD-7.
· Provides transition support services, generally based on the Coleman model of Care Transition Intervention.
· Works with supervisors and other healthcare providers, hospital discharge planners, skilled nursing facility staff, and staff at the client’s health home to implement services and analyze the disposition of cases.
· Coaches the client/beneficiary to build confidence and competence in four conceptual areas, or “pillars”: medication self-management, use of a patient-centered health record, primary care and specialist follow-up, and knowledge of red flags of their condition and how to respond.
· Performs facility visits, home visits, and follow up telephone calls to develop critical coaching relationships, to empower clients/beneficiaries to take an active and informed role in their discharge planning and introduce them to the patient-centered Personal Health Record.
· Tracks coaching-related metrics and reports on intervention progress.
· Coordinates follow-up activities and referrals with other programs including the Family Caregiver Support Program and AAADSW/HCS Medicaid Case Management.
· Coordinates and communicates regarding the client’s/beneficiary’s post-discharge status with all involved health care providers including, but not limited to: primary care, mental health, specialty care, and pharmacy.
· Identifies and addresses barriers to overcome impediments to accessing health care and social services.
· Provides referrals and advocacy for clients/beneficiaries and their caregivers to community long term services and supports, which includes family caregiver programs, nutrition programs, in-home care and case management.
· Provides teaching about self-management of the client’s/beneficiary’s chronic health condition and provides resource links to ongoing chronic disease self-management support services.
· Develops and maintains complete and concise client/beneficiary files in compliance with policy to appropriately document activities performed for the client/beneficiary and all elements required for specific programs.
· Maintains all required documentation related to services provided and conforms to monthly deadlines.
· Participates in staff meetings, public education and provider training sessions, as appropriate.
· Develops and maintains relationships with community agencies and organizations that have the potential to provide resource support to the program or individuals.
· Prepares correspondence, memos, and client related written materials, as appropriate.
· Participates in continuing education and training programs.
· Works collaboratively with multi-disciplinary teams involving nurses, case managers and case aides.
· Attends required meetings and trainings.
Knowledge, Skills, and Abilities:
· Ability to travel to and from client’s homes and other community agencies which might not be ADA accessible.
Minimum Qualifications:
· Training in Coleman CTI or other coaching modality is desired.
· Experience working on cross disciplinary, cross-organizational teams.
· Experience meeting and working with people in homes and other medical and community settings.
· Possession of a valid driver’s license and minimum state-required vehicle insurance and have use of reliable transportation.
Job Types: Full-time, Part-time
Pay: $24.00 - $30.00 per hour
Benefits:
Schedule:
Application Question(s):
services and behavioral sciences; or
Education:
Experience:
Shift availability:
Ability to Relocate:
Work Location: In person
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