Complex Case Manager

JOB DUTIES AND RESPONSIBILITIES:

• Manages a caseload of high-risk patients including readmissions, high utilizers, and patients with complex social or medical needs.

• Caseload can consist of cases that span more than one campus.

• Acts as a resource for other care managers and the treatment teams on complex patient issues affecting discharge.

• Completes standardized documentation to ensure consistency and compliance with regulations.

• Assists patients in accessing community resources, outpatient follow-up, and social support services to facilitate care across the continuum as well as reduce unnecessary readmissions.

• Attends guardianship hearings or other meetings outside of a hospital setting as necessary for the caseload of patients.

• Organizes and facilitates team meetings with patients, families and members of the healthcare team as needed to coordinate care.

• Facilitates transitions to outpatient services, which include but are not limited to home care, post-acute facilities, or other post-acute services.

• Collaborates with the patient, family or other caregivers and multidisciplinary team to design a discharge plan respective of the patient's needs and goals. 

• Facilitates communication among all treatment team members.

• Manages length of stay and readmissions by proactively identifying and mitigating issues and barriers to care and a successful discharge plan.

• Updates the care team, patient/family as to the status of the discharge plans.  Re-evaluates and revises the discharge plan as additional information is acquired.

• Proactively considers options such as palliative care, homecare and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of readmissions.

• Issues applicable state/federal regulatory notices as applicable ie.) Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle