Case Manager - Acute Care Management - Full Time - Day Shift - Brunswick

SGHS•Brunswick, GA

About The Position

The Case Manager in Acute Care Management proactively assesses patients and evaluates possible next levels of care, coordinates care planning and progression, and collaborates with the healthcare team to develop individualized plans of care and discharge plans. The Case Manager initiates discharge planning at the initial assessment and coordinates revisions with the healthcare team, documenting plans and updates accurately in the medical record. The role supports coordinated patient care through routine communication with healthcare team members, participation in unit and team rounds, effective handoffs, and appropriate referrals to the Physician Advisor, Clinical Social Work, transportation coordinator, and Care Management assistant. The Case Manager manages required Medicare beneficiary notices and related procedures, identifies avoidable days and variances, documents case management processes, and provides weekend staff with information needed for effective follow-up and continuity of care. The role also identifies patients with medical, psychological, financial, or social needs and refers appropriate cases to the social work care manager for advocacy and follow-up.

Responsibilities

Assess cases proactively and evaluate possible next levels of care.
Coordinate care planning and progression with healthcare team members.
Collaborate with the medical team to formulate individualized plans of care and discharge plans.
Initiate discharge planning upon initial assessment and coordinate changes to the plan with the healthcare team.
Document care and discharge plans accurately in the medical record and update documentation as plans change.
Identify patients and families with complex psychosocial needs and refer cases to Clinical Social Work in a timely manner.
Oversee required notification processes for Medicare and Medicare Managed Care beneficiaries’ rights, including Hospital Discharge Appeal Rights, Condition Code 44, Election of Lifetime Reserve Days, Medicare Outpatient Observation Notice, and Hospital Issued Notice of Non-coverage.
Communicate routinely with healthcare team members during rounds and throughout the day to ensure patient care needs are addressed.
Refer appropriate issues and cases to the Physician Advisor in a timely manner.
Communicate and coordinate with peers to meet patient needs, including handoffs and coverage of care.
Direct timely and appropriate referral management tasks to the transportation coordinator and/or Care Management assistant for completion of the transition plan.
Provide comprehensive documentation of case management processes in the electronic medical record as required by policy.
Provide weekend staff with comprehensive information to support effective follow-up and continuity of care.
Identify avoidable days and variances and document them in the department’s electronic system before discharge.
Assess patients with medical, psychological, financial, and social needs and refer them to the social work care manager for appropriate follow-up and advocacy.