DCH Health System

Identifies and reports process improvement opportunities by capturing delays in care by documenting avoidable days in MIDAS per guidelines.. In collaboration with the appropriate services, arranges home care, DME and infusion and/or post acute services in partnership with the social worker.. Serves in obtaining legal guardianship, competency determinations, adoption related situations and all cases where Adult or Child abuse is a concern.. Identifies cases which would benefit from palliative care and elicits palliative consults as needed.. Skill in using Microsoft office applications, and Information systems including but not limited to MIDAS.Demonstrated critical thinking skills and ability to prioritize work load.

care manager

Overview The Care Manager works collaboratively with interdisciplinary and healthcare team members, both internal and external to the organization to facilitate patient care through effective utilization and monitoring of healthcare resources and assumes a leadership role to achieve safe discharge planning along with desired clinical and financial outcomes. The Care Manager coordinates care and services through the acute care episode and across the continuum. Responsibilities AssessmentCompletes a face to face assessment of all new patients in caseload within 24 hours or next business day to identify appropriateness for acute care, level of care and to anticipate high level care planning needs. Screens high risk patients with lace score greater than or equal to 10 to reduce 30 day readmissions. Consults with attending physicians regarding potential care transition barriers identified as a result of this process.Assumes transition process in collaboration with the multidisciplinary team and patient/family and assists with executing the plans and interventions to facilitate the stay and manage the length of stay. Facilitates patient care conferences/complex case conferences proactively as needs are identified to reduce avoidable readmissions. Utilization ManagementProvides an Important Message notice and choice on Medicare patients as appropriate. Identifies and reports process improvement opportunities by capturing delays in care by documenting avoidable days in MIDAS per guidelines. Monitors and facilitates appropriateness of tests/procedures, consultation, treatment plans and resource utilization.Care Coordination, Collaboration, and Transition PlanningCollaborates with social workers for patients with complex, clinical, financial and psycho-social needs.Reviews physician orders and patient progression on a daily basis and intervenes with care coordination as needed. Collaborates with other departments to eliminate barriers, as necessary.Actively participates in multi-disciplinary rounds, long stay rounds and meetings that promote comprehensive and coordinated care plans and monitors progress against goalsProvides clear and timely information on the patients plan of care to the next providerBuilds trusting relationships with attending physician, patient and/or family and other members of the healthcare team. Maintains contact with the patient, family, physician, and team members to ensure the most cost effective plan of care is being carried out and appropriate in network providers are being utilized.Establishes a caring relationship with patients and their caregivers, promotes patient engagement and guides patients/families through the transition phaseIn accordance with established clinical guidelines/standards of care establishes a comprehensive care transition plan and will organize, secure, integrate and modify resources necessary to meet the goals stated in the assessment plan.Documents plan of care and updates /changes in plan of care in the electronic medical record. In collaboration with the appropriate services, arranges home care, DME and infusion and/or post acute services in partnership with the social worker. Maintains good working relationships with community providersAssists with medication issues for patients on an as needed basis.Serves in obtaining legal guardianship, competency determinations, adoption related situations and all cases where Adult or Child abuse is a concern. Is responsible for making sure all legal documents are completed. Collaborates with the Corporate Director and Manager of Case Management as needed. Provides counseling and support as needed. Identifies cases which would benefit from palliative care and elicits palliative consults as needed. Education and ProfessionalismServes as a resource to patients, physicians, Administration, and other disciplines regarding care management functions and expertise.Participates in defining, maintaining and interpreting care management standards of practice Assesses and educates patients and families on community agencies and resourcesEducates and reinforces the early identification of changes in patient condition and changes in care transition plansAssumes responsibility for own professional growth and is willing to share knowledge with coworkers and other health care providers. Performs assigned work safely, adhering to established departmental safety standards rules and practices; reports to supervisor , in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients, and visitors DCH StandardsMaintains performance, patient, and employee satisfaction and financial standards as outlined in the performance evaluation.Performs compliance requirements as outlined in the Employee Handbook.Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.Identifies and reduces unsafe practices that may result in harm to patients, visitors and employeesRecognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.Requires use of electronic mail, time and attendance software, learning management software and intranet.Must adhere to all DCH Health System policies and procedures.All other duties as assigned. Qualifications RN with 2 years' experience in a hospital setting with 1 year experience in utilization and/or case management requiredBSN and or related bachelor's degree in a healthcare field preferredCurrent Alabma or compact RN licensure in good standingKnowledge of managed care, governmental payers, and third party reimbursement.Skill in using Microsoft office applications, and Information systems including but not limited to MIDAS.Demonstrated critical thinking skills and ability to prioritize work load.Ability to exercise clinical judgment and autonomous decision making.Strong interpersonal skills relative to both professional and lay interactions.Strong organizational skills.Demonstrated working knowledge of performance improvement activities.Demonstrated working knowledge of data management/reporting practices.Strong communication skills.WORK CONTEXTAbility to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contactsAbility to provide guidance and direction to subordinates, including performance standards and monitoring performanceAbility to encourage and build mutual trust, respect, and cooperation among team membersAbility to communicate with people outside the organization and represent the organization to the public, government, and other external sourcesAbility to work independently or within a team structureMust be able to read, legibly write, speak, and comprehend EnglishMust be able to operate a telephone and computerMay be exposed to environmental cleaning chemicalsPHYSICAL FACTORSRequires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light workAbility to tolerate prolonged periods of sitting, standing, and/or walkingAbility to reach reasonable distances to handle equipmentGood manual and finger dexterityMust be able to perform the duties with or without reasonable accommodationHearing and vision must be normal or corrected to within normal rangePhysical presence onsite is essential

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