Senior Case Management Specialist, Post-Acute - South Shore Health

Job Description Summary

Under the general supervision of the Care Progression Manager acts as a patient advocate / Case Manager Specialist to South Shore Health System clients. Works in coordination with RN Case Managers and Care Progression Leadership to coordinate, negotiate, procure services and resources for and manage the transitional care planning of patients to facilitate achievement of quality and cost efficient patient outcomes.Responsible to work with a multi-disciplinary patient care team to optimize the discharge planning mission for patients, from admission to discharge, which requires varying degrees of follow-up and follow through, including fostering, executing, expediting an efficient and effective discharge process.Works collaboratively with the interdisciplinary team internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. Attends weekly Clinical High Risk Outlier meetings and other necessary huddles to identify patients requiring addition resources to secure a safe and comprehensive discharge plan. May require an occasional site visit to Rehab facility for ongoing discharge planning. The lead Post-Acute Case Management Specialist for CCC will provide coverage for the Care Connect Center. Responsibilities would include working collaboratively and collegially within and externally to the Care Progression department and South Shore Health Organization. Answers phones, monitors the CM Care Connect Tiger Text Role, Monitors the referral work queue, facilitates the scheduling of appointments, assists the case management team with connecting patients and families to appropriate community resources, coordinates referrals to system and community programs, facilitate the setup of ordered DME and/or home equipment, assist to setup transportation, and promote the management of patients in the community as appropriate.

Job Description

ESSENTIAL FUNCTIONS

1 - Working collaboratively with the RN Case Manager/Licensed Clinical Social Worker, the lead Post-Acute Case Manager Specialist coordinates and facilitates discharge planning of patients within a defined caseload.

2 - The lead Post-Acute Case Manager Specialist works with the RN Case Manager/Licensed Clinical Social Worker to identify and prioritize workflow through identification of patient specific needs, department needs and or unit based needs.

3 - The lead Post-Acute Case Manager Specialist engages and utilizes the clinical expertise of the RN Case Manager/Licensed Clinical Social Worker as a resource to procure and support a high quality discharge plan.

   a - Executes and implements a safe and effective discharge plan based on the case management assessment in accordance with the Conditions of Participation.

   b - Makes and documents appropriate changes to discharge plan when necessary.

   c - Proactively uncovers barriers to early/timely discharge and overcomes them

   d - Completes the Medical Necessity form for post discharge transportation.

   e - Identifies patient Health Care Proxy’s or establishes as needed.

   f - Attends weekly Clinical High Risk (CHR) meeting.

   j - Fosters patient and family involvement in discharge planning.

4 - Communication: The lead Post-Acute Case Manager Specialist is aware of his/her capabilities and limitations and seeks advice/direction from RN Case Manager/Licensed Clinical Social Worker through the use of huddles as needed throughout the work day.

   a - The lead Post-Acute Case Manager Specialist, communicates the safe and effective discharge plan to clinical staff, patient, family, and caregivers; incorporating additions and changes to the discharge plan

   b - Escalates any patient questions and / or concerns to the RN Case Manager or Manager of Care Progression as need arises.

   c - Refers any payer negotiation to the Care Progression Manager.

   d - Escalate any provider concerns related to payer issues, or clinical concern to the Care Progression Manager or discharge planners.

   e - Acts as a communication liaison between all members of the care team and the patient/family as it may pertain to discharge choices, concerns, and barriers.

   f - Maintains up to date communication with whole team as to discharge plan progress and/or delays.

   g - Maintain up to date documentation reflective of changes who, and why the changes were made in EMR.

   h - Uses SBAR to communicate with peers

   i - Updates all outside providers via telephone, fax or other when a change in discharge plan impacts the place and date of transfer

   j - Understands the need to work with the RN Case Manager if patient condition and medical complexity changes which is impacting length of stay. Facilitate coordination and documentation of discharge appointments and outpatient follow up.

5 - Ensure that patient has received all information related to choice of follow-up care facilities, and/or public or private care providers, including explaining all elements of discharge, continuum of care needs and available options to patients, families, RN Case Manager, CMS, Social Worker and/or care givers.

   a - Ensure that, at minimum, 3 referrals are processed for continuum of care providers, taking into account insurance and/or other limitations when offering choices.

   b - Document choices provided and selections made by patient and/or family.

   c - Expedite and process referrals, per department standards, including requesting and tracking screenings and acceptances of patients by care providers, expediting responses from provider facility personnel as necessary.

   d - Document response by providers.

6 - Reference resources to confirm provider benefits for care choices, including public, private, and governmental payers and established / preferred relations.

   a - Maintains current knowledge of discharge planning, as specified by federal, state, private insurance guidelines

   b - Maintains a working knowledge of the resources available in the community for patient/family.

   c - Maintains a working knowledge of the requirements of the payers most frequently seen with the patient population

   d - Maintains a working knowledge of the established and preferred relationships as defined in service area.

7- Complete and process required documentation, such as discharge plans, and government program forms to meet discharge plan metrics.

   a - Complete Long Term placement forms as required in a timely fashion so not to delay any transfer.

   b - Process and confirm the completion of MOLST forms, when applicable, as to not delay any transfer.

   c - Complete any other patient related documentation to comply with legal and hospital requirements for discharge, and secure necessary signatures, patient and otherwise.                                                                                                                                                   

   d - Confirm the presence of Health Care Proxy forms, if appropriate.

   e - Obtain all required patient signatures.

   f - Confirm the presence of all necessary documentation, such as discharge summary, medication reconciliation, etc.

8 - Arrange for and confirm transportation needs

   a – Request Circulation needs from Unit Clerk, as applicable

9 - Along with the RN Case Manager/Licensed Clinical Social Worker, is responsible for department operational excellence, regarding safe and effective discharge planning; assures department delivers quality services in accordance with applicable policies, procedures and professional standards.

   a - Manages all activities so that quality services are provided in an efficient and effective manner.

   b - Participates in departmental and organizational Quality Improvement

   c - Has an awareness of departmental productivity measurements including LOS and utilization.

   d - Follows department policies, procedures, and standards of care that support operational excellence and productivity measurements

10 - Technology - Embraces technological solutions to work processes and practices.

   a – Epic, Strata Health, Sharepoint, Word, Excel and others.

11 - Safety Awareness - Fosters a "Culture of Safety" through personal ownership and commitment to a safe environment.

12 - Support the vision and mission of South Shore Hospital and those of the Care Progression department.

   a - Demonstrated professional behavior in attitude, attendance, performance, and attire.

13 - Precepts new hires.

14 – Participates in a Department Improvement process such UBC/Shared Governance, Peer Review, skill days as needed.

15 - Works with Clinical Managers, Attending RNs and the ACNO to create, innovate, and support new initiatives across the continuum of care.

JOB REQUIREMENTS

Minimum Education - Preferred

BS in Health Related field, Licensed Social Worker, CCM or LPN preferred.  Knowledge of basic medical terminology required. Demonstrated competency in basic computer and keyboard skills Required, Epic, Strata Health and SharePoint preferred.

Minimum Work Experience

Experience within an admissions and/or discharge function desirable, especially in a high stress area. Experience working with patients and families, elders and their caregivers, and/or various other community populations desirable.

Required additional Knowledge, and Abilities

Excellent communication skills required; ability to work independently and under very stressful situations required. Ability to time manage, set priorities and self-organization will be essential to success of employee.  Ability to work within a multidisciplinary team and in collaboration with the RN Case Manager/Licensed Clinical Social Worker required.