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Inpatient Case Manager

Inpatient Case Manager

Job Summary

The case manager’s primary responsibility is to coordinate the provision of care. Works closely with both internal and external individuals and organizations to ensure the coordination of care. Meets the patient and their caregivers or support system to orient them to the process of rehabilitation and provide an overview of their specific program. Completes the initial evaluation and shares this information and assists the treatment team in building a treatment plan that has the goal of the patient returning home. Ensures communication with the patient and caregivers through contacts that occur at least two (2) times per week. Monitors the patient and family’s progress towards their short- and long-term rehab goals, discharge plan and outcomes of care. Ensures that all DME, medical equipment and follow-up services are arranged prior to discharge in a manner that meets the patient’s and caregiver’s needs. Educates patient on follow-up therapy services available and makes referral to follow up OP and/or Home Health (HH) Services. Provides information for PAI data collection process for IRF through the initial assessment and discharge summary documentation forms. Acts as the patient’s advocate during the inpatient stay and ensures patients’ involvement throughout their rehabilitation programs. Makes arrangement for transfer to alternative levels of care when discharging to home is not an option. May provide discharge planning duties for patients on the SubAcute Unit.

Scope of authority / Leadership responsibilities / Reporting relationships/ Identification of work team

Under the general direction of the Case Manager (CM) Supervisor. The position serves patients twelve years of age and older and all clinical programs that fall within the inpatient / subacute facilities. Must work in cooperation with various treatment team members, external vendors, the OP/ HH liaison and a variety of health care providers. No direct supervisory responsibility.

Minimum Qualifications / Equivalents

Education, experience, licensure, certification, and/ or specific skills and time frame for proficiency where appropriate.

Education:

  • Minimum of a bachelor’s degree in a health care or related field preferred in addition to those with an RN or LPN.

Experience:

  • Minimum of one (1) year experience in the field of healthcare with experience in a hospital or rehabilitation setting.
  • Inpatient hospital experience preferred.

Skills / Competencies

  • Excellent organization skills.
  • Personal initiative.
  • Excellent written and verbal skills.
  • Excellent ability to communicate with individuals of all backgrounds and functional levels.

Physical/ Mental Requirements

Position requires the ability to frequently:

  • Receive detailed/technical information from a variety of sources and use it effectively in decision-making.
  • Effectively manage time while coordinating a variety of challenging tasks.
  • Move about the hospital environment.

Environmental working conditions

Position requires occasional to frequent exposure to:

  • Disease
  • Blood, body tissues or fluids
  • High and low temperature
  • Hazardous materials such as chemicals or toxic materials
  • Bodily injuries

Clinical Standards

Evaluation

Demonstrates the ability to complete the initial evaluation in a manner that allows input from the patient and family to be reflected in the initial pre-staffing, staffing and plan of care. Ensures that patients and their caregivers are properly oriented to their roles in their rehabilitation programs.

  • Completes all information on the initial evaluation within one business day of admission.
  • Provides the patient and their caregiver an orientation to rehab in a timely manner.
  • Ensures that patients / caregivers understand the importance of their involvement in their rehabilitation programs and that they are encouraged to attend as many treatment sessions as possible.
  • Presents discharge plan to team during pre-staffing and staffing.
  • Demonstrates an active role in the development of the patient’s plan of care.
  • Evaluates for any special circumstances which could negatively impact the patient’s progress / safety.

Discharge Planning

Demonstrates meaningful, accurate and consistent communication with the patient and their family

  • Meets patient / caregivers on day of admission.
  • Contacts family again within two business days of admission.
  • Communicates patient status in a meaningful manner to caregivers / family at least twice per week during the hospitalization.
  • Ensures that any barriers to an effective, safe and timely discharge to home are addressed in a proactive manner.
  • Ensures that the patient / family are informed of the discharge plans and any issues that may influence the plan.
  • Makes follow-up contact within 72 hours of discharge to all patients who are being discharged to home.
  • Ensures that all problems associated with patient / family communication are reported immediately to the CM Supervisor.

Makes timely referrals to related service providers / agencies and assists the patient / family in obtaining needed services and resources

  • Includes making arrangement for handicap parking stickers, assists with application for short-term disability, FMLA and other needed arrangements.

Demonstrates the ability to effectively coordinate family training

  • Coordinates family training within the first week of the patient’s stay and as defined by the treatment plan after that.
  • Schedules family training and coordinates schedules for all involved parties.
  • Meets with people being trained both prior to and after the training to:
    • Explain the goals of the training,
    • Provide a schedule of the training,
    • Show them to their first therapy,
    • Assess for training effectiveness at the end of the training,
    • Assess for any barriers which could impair a safe, timely and effective discharge to home,
    • Explain the importance of proper follow up care,
    • Assist family in choosing a preferred DME and OP / HH provider, and
    • Educates the patient on other discharge issues such as insurance coverage of medications.
  • Documents and communicates findings with the treatment team.
  • Integrates assessment of the training into the patient’s plan of care.
  • Ensures that all problems associated with family trainings are reported immediately to the CM Supervisor.

When discharge to home is not possible, coordinates the patient’s discharge to an alternative level of care.

  • Assists patient / family in choosing a SNF, ALF, subacute or other living arrangements.
  • Ensures that proper documentation is sent / communicated to the chosen agency in a manner consistent with hospital policy.
  • Communicate plan to patient /family, MD, nursing and team promptly and provide updates as needed.
  • Makes proper arrangements for transportation to the facility.
  • When the placement is planned as a transition phase, makes contact with the patient / family around the time of transition to assist with ensuring that the transition occurs when appropriate.
  • When the placement is planned as a transition phase, makes contact with the discharge planner at the facility to identify which agency the patient will be receiving HH services from and communicates this information to the Siskin Hospital OP / HH liaison.
  • Completes all necessary documentation.
  • Ensures that all problems associated with discharge to alternative level of care are reported immediately to the CM Supervisor.

Ensures a coordinated delivery of prescribed DME, other medical equipment, supplies and devices through an agency chosen by the patient and family.

  • Ensures that DME is discussed during all pre-staffings.
  • Therapists will recommend a provider to the discharge planner if the family needs help in choosing one, particularly in the case of custom wheelchair seating.
  • Ensures that the patient’s insurance company does not dictate a provider.
  • Short-stay patients should have the prescriptions filled out at the first pre-staffing.
  • Patients with longer lengths of stay should have the prescriptions filled out at the second pre-staffing.
  • Assists the patient / family in choosing a preferred DME provider.
  • Ensures that the DME is provided by a minimum number of providers to minimize the complexity of the discharge instructions.
  • Ensures that DME is delivered prior to discharge to ensure that the proper equipment is delivered and the necessary adjustments are made.
  • Ensures all necessary documentation is completed.
  • Ensures that all problems associated with DME are reported immediately to the CM Supervisor.

Ensures a coordinated and timely provision of prescribed OP Therapy Services

  • Ensures that the need for OP therapy is discussed during all pre-staffing.
  • Ensures that the patient’s insurance company does not dictate a provider.
  • Short-stay patients should have the prescriptions filled out at the first pre-staffing.
  • Patients with longer lengths of stay should have the prescriptions filled out at the second pre-staffing.
  • Assists the patient / family in choosing a preferred OP provider (when indicated).
  • Educates the patient and the family on what proper follow-up care is and the importance of it.
  • Provides tours of OP areas on main campus for patients / families choosing a provider.
  • Ensures that the OP provider chosen can meet the needs of the patient,
  • Communicates the preferred provider to the OP / HH Liaison a minimum of three (3) days before discharge.
  • Communicates the date and times of the OP Therapy visits to the patient / family prior to the day of discharge.
  • Ensures all necessary documentation is completed.
  • Ensures that all problems associated with arrangements of OP Therapy are reported immediately to the CM Supervisor.

Ensures a coordinated and timely provision of prescribed HH Services

  • Ensures that the need for HH services is discussed during all pre-staffings.
  • Ensures that the patient’s insurance company does not dictate a provider.
  • Short-stay patients should have the prescriptions filled out at the first pre-staffing.
  • Patients with longer lengths of stay should have the prescriptions filled out at the second pre-staffing.
  • Assists the patient / family in choosing a preferred HH provider (when indicated).
  • Educates the patient and the family on what proper follow-up care is and the importance of it.
  • Ensures that the HH provider chosen can meet the needs of the patient.
  • Communicates the preferred provider to the OP / HH Liaison a minimum of three (3) days before discharge.
  • Ensures that the home health agency communicated with the patient / family prior to the day of discharge.
  • Ensures all necessary documentation is completed.
  • Ensures that all problems associated with arrangements of HH Services are reported immediately to the CM Supervisor.

Coverage

Demonstrates the ability to provide basic coverage in other programs / areas.

  • This includes other inpatient teams as well as the SubAcute Unit.

Other Duties

Carries out other duties as assigned by supervisors

  • Includes the daily discharge dispositions.
  • Rotate on call with co-workers every seven (7) weeks.

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Siskin Hospital is a Smoke-Free Facility!

In order to further our mission of helping others achieve and maintain healthy lives, effective March 1, 2017, Siskin Hospital for Physical Rehabilitation will no longer hire individuals who use tobacco or nicotine products in any form. Siskin Hospital recognizes the major importance of employees’ health and the responsibility of maintaining a healthy and safe environment for all employees, volunteers, patients and visitors. Therefore, all individuals who are offered a position with Siskin Hospital are screened for illegal drug, alcohol, and/or tobacco/nicotine as part of the post-offer health screening. Individuals whose post-offer health screening results are verified positive for illegal drugs, alcohol and/or tobacco/nicotine use, and/or whose reference and/or background checks are verified unsatisfactory, will be disqualified from employment, their job offer will be withdrawn, and they may be disqualified from applying for employment for one (1) year from the date of the post-offer health screening.

The Cultural Competency and Diversity Plan of Siskin Hospital is designed to help create and maintain an environment that promotes inclusion. Overall, creating the best experience for our patients and our employees. Caring People, Changing Lives.

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If you are interested in joining our family, please email your resume to Human Resources at recruitment@siskinrehab.org.