Facilitate the coordination of care, from admission through discharge, with focus on realistic treatment outcomes within the scope of available resources. Oversee the assessment, planning, facilitation, coordination, evaluation and advocacy for options and services to meet a patient and family's comprehensive health needs and to promote quality cost effective outcomes. Collaborate with the interdisciplinary team, patient and family, as well as various departments within and outside the hospital to assure timely and appropriate discharge planning and cost effective outcomes.
* Assessment of the patient's health and psychosocial needs is conducted per established guidelines. * Case management plan is developed collaboratively with the interdisciplinary team, patient and family to maximize health care responses, quality and cost effective outcomes, incorporating patient and family goals, expectations, and preferences into the development of the interdisciplinary plan of care * Communication and coordination is actively promoted between members of the interdisciplinary team, the payer and the community to minimize fragmentation of services and to maximize outcomes. * Patient centered team meetings are planned and conducted to coordinate healthcare team members and third party payers to achieve treatment outcomes and discharge planning goals * Education is provided to the interdisciplinary team, the patient and the family about treatment options, community resources, insurance benefits and psychosocial concerns to ensure timely and informed decisions. * Patient and family are empowered to problem solve to achieve desired outcomes and promote patient self determination. * Appropriate use of health care services and allocation of resources is encouraged to improve quality of care and maintain a balance with cost effective care on a case by case basis. * Appropriate resources are identified to provide discharge services and promote a safe transition to the next most appropriate level of care. * Discharge plan is developed in collaboration with healthcare team and family and meets patient needs and financial requirements. * Culturally competent care is displayed to identify the patient's cultural needs and incorporate them in the development of the discharge plan. * Patient education and support is provided to ensure a smooth transition from acute setting, through the SRN stay and transition to discharge using established standards. * Documentation is completed in adherence to department standards. * Third party coverage guidelines are adhered to for each patient situation. * Additional department, organization, or network activities are completed per established objectives. * PCC Organizational Values of Innovation, Collaboration, Accountability, Respect, and Excellence are upheld.
* 5 years of related experience. * Case management, utilization review, or discharge planning experience in an acute, rehabilitation, skilled nursing or outpatient setting is required.
* Health plan experience in utilization review and case management will be considered.
* Current, unrestricted license to practice in Massachusetts in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline. Examples are Nursing, Physical Therapy, Occupational Therapy, Speech/Language Pathology, LCSW, Respiratory Therapist or Rehabilitation Counselor.
Skills (Specific learned activity gained through training (e.g. computer skills, keyboarding, presentation, CPR, ACLS, etc.)
* Certification in Case Management preferred. * Knowledge of community services and the healthcare systems required. * Knowledge of criteria and levels of care is desirable. * Computer proficiency required. Microsoft office applications preferred with ability to learn new software.
* Highly developed communications and interpersonal skills, working with diverse population. * Work independently, be self-directed and contribute as a member of a team. * Anticipates challenges and develops and implements strategies for addressing them. * High level of service delivery. Demonstrate initiative with ability to prioritize work, meet deadlines and adapt to changing situations. * Attention to detail.