Case Manager

Job Description
osition Summary
The purpose of this role is to facilitate appropriate care delivery to high-risk patients with the goal of keeping the patient safely at home.

In order to provide appropriate care to meet the needs of the patient, accurate patient assessment must be validated with identification of what matters most to the patient.

Care managers assesses/monitor that best practice utilization is executed by multi-disciplinary care coordination supports the identified patient needs through effective resource utilization.

This role mentors’ staff and peers to build confidence in competence of best practices’ impact in achieving successful patient outcomes.
Oversight of patient Plan of Care in order to ensure appropriate interventions and visit schedules, orders are in place for every patient.

Ensure that appropriate skilled services are planned and adjusted as needed in order to achieve patient goal while maintaining fiscal accountability through accuracy, timeliness and avoiding duplication.
Qualifications
Licensed RN, PT, OT, ST.
Oasis certification preferred but not required.
Strong preference will be given to those with Home Health and/or Hospice experience.
Essential Functions
Ensure a thorough Assessment has occurred on each patient (Oasis/HIS accuracy)
Plan of Care created around patient centered goal
– “What Matters Most” needs assessment drives selection of interventions
Review Plan of Care, orders to ensure Best Practices are being implemented consistently including CALL US FIRST instruction
Using an interdisciplinary team approach, oversee and approve visit schedule (right discipline, right care, right time) and assist team with coordination to include phone calls and video visits as additional touch points
Facilitate Care Management meetings
Monitor effectiveness, focus on achieving optimal outcomes, which integrate maximum episode productivity (outcomes and visit utilization, what did we expect the patient to look like at dc?

Achieved?) o Clinical Managers attend, participate, and ensure clinician participate in and execute key performance behaviors that support clinical excellence, patient experience and regulatory compliance o Patients who were hospitalized are studied, as well as, patients who are complex, have high utilization, or reveal a need to adopt and integrate standardized best practices
Case study, discussion and related best practice education promotes the concepts of episode productivity
– achieving the optimal clinical outcome within the most efficient use of clinical resources
Providing clinicians and managers a forum for ongoing learning is supportive of clinicians and patients; enhancing mindfulness of goal directed care provision.

This process provokes and supports critical thinking and team practice, a focused approach to each visit within the episode.
Partner with Clinical Managers to educate staff on risk stratification, prognostic indicators for end of life and matching orders to support care needs across the disease state
Integration of best practice, improvement in clinical outcomes, and control of visit utilization, supports effective care delivery
Maintain focus on symptom management as a strategy to reduce avoidable hospitalizations
Monitor patient care plan and schedule to ensure comprehensive patient assessment at every visit and proper interventions and orders based on best practice, D/C planning throughout episode including required notices
Collaborate with Ed and clinical manager to support clinicians practice and skill development including point of care documentation
Utilize available resources within CHS
Ensure completeness of documentation in timely manner oversight and evaluation of timely and accurate oasis/HIS completion and submission
Review for Compliance with regulatory standards
Spearhead innovative care approaches to support patient outcomes and the triple aim
Recommend treatment interventions, approaches and programs and processes incorporating team members across the continuum of care (standing order sets, telehealth, video visits, teledoc)
Evaluate patient risk level and ensure that appropriate interventions are in place based on patient risk, including but not limited to remote patient monitoring, virtual visits by APRN, additional touch points from office to check on patients between in person visits.
Investigate and work collaboratively with physician groups to evolve continuum
– based care protocols for commonly served diseases.

Protocols may/should also extend into recognition and service of end-of-life care as indicated.
Knowledgeable of the agency’s adverse events (specifically infections, emergent care and hospitalization of patients served) and correlating study of best practice methodology which mitigates these risk
Benefits
Competitive salary
A rich benefits package, including medical, dental, life and long-term disability insurance
401(k) plan (matched)
Generous paid time off
Continuing education reimbursement
Apply today and take your place among the stars with Constellation!

#INDSJ
Requirements
Qualifications
Licensed RN, PT, OT, ST.
Oasis certification preferred but not required.
Strong preference will be given to those with Home Health and/or Hospice experience.

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