Rehab Care Manager /RN

DCH Health System•Northport, AL

19d•Onsite

About The Position

The Rehab Care Manager works collaboratively with internal and external interdisciplinary and healthcare team members to facilitate patient care through effective utilization and monitoring of healthcare resources. The role provides leadership in safe discharge planning and in achieving desired clinical and financial outcomes. The Rehab Care Manager coordinates care and services throughout the acute rehabilitation stay and across the continuum. The position assesses patients, coordinates transitions and discharge planning, monitors resource utilization, and collaborates with patients, families, physicians, social workers, and other providers. It also provides education, counseling, and support; documents care plans in the electronic medical record; and serves as a resource on care management functions and expertise. Physical presence onsite is essential.

Requirements

Registered Nurse with at least 2 years of experience.
Current Alabama RN licensure.
Knowledge of managed care, governmental payers, and third-party reimbursement.
Skill using Microsoft Office applications and information systems, including but not limited to MIDAS.
Demonstrated critical-thinking skills and ability to prioritize workload.
Ability to exercise clinical judgment and make autonomous decisions.
Strong interpersonal skills in professional and lay interactions.
Strong organizational skills.
Demonstrated working knowledge of performance-improvement activities.
Demonstrated working knowledge of data-management and reporting practices.
Strong communication skills.
Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
Ability to provide guidance and direction to subordinates, including establishing performance standards and monitoring performance.
Ability to encourage mutual trust, respect, and cooperation among team members.
Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
Ability to work independently or within a team structure.
Ability to read, legibly write, speak, and comprehend English.
Ability to operate a telephone and computer.
Ability to tolerate prolonged periods of sitting, standing, and/or walking; reach reasonable distances to handle equipment; and demonstrate good manual and finger dexterity.
Ability to perform the duties with or without reasonable accommodation.
Hearing and vision must be normal or corrected to within normal range.
Physical presence onsite is essential.

Nice To Haves

BSN and/or a related bachelor’s degree in a healthcare field.
Relevant experience in utilization and/or case management.

Responsibilities

Complete a face-to-face assessment of each new patient in the caseload within 72 hours or the next business day to determine appropriateness for inpatient rehabilitation, level of care, and anticipated care-planning needs; consult attending physicians about identified transition barriers.
Coordinate the transition process with the multidisciplinary team and patient or family, and help execute plans and interventions that facilitate the stay and manage length of stay.
Facilitate patient care conferences and complex case conferences proactively to reduce avoidable readmissions and delayed discharges.
Provide Important Message notices and choice to Medicare patients as appropriate.
Identify and report process improvement opportunities.
Monitor and facilitate the appropriateness of tests, procedures, consultations, treatment plans, and resource utilization.
Collaborate with social workers on patients with complex clinical, financial, and psychosocial needs.
Review physician orders and patient progression daily and intervene with care coordination as needed; collaborate with other departments to eliminate barriers.
Participate actively in interdisciplinary team conferences and meetings, promote comprehensive coordinated care plans, and monitor progress against goals.
Provide clear, timely information about the patient’s plan of care to the next provider.
Build and maintain trusting relationships with attending physicians, patients and families, and healthcare team members; maintain contact to support cost-effective care and use of appropriate in-network providers.
Establish caring relationships with patients and caregivers, promote patient engagement, and guide patients and families through transitions.
Establish comprehensive care transition plans in accordance with clinical guidelines and standards of care; organize, secure, integrate, and modify resources needed to meet assessment-plan goals.
Document care plans and updates or changes in the electronic medical record.
Arrange home care, durable medical equipment, infusion, and other post-acute services with appropriate services and the social worker; maintain working relationships with community providers.
Assist with medication issues as needed.
Assist with legal guardianship and competency determinations, adoption-related situations, and cases involving abuse; ensure legal documents are completed and collaborate with the Director of Rehab as needed.
Provide counseling and support as needed; identify cases that may benefit from palliative care and request palliative consultations as appropriate.
Serve as a resource to patients, physicians, Administration, and other disciplines regarding care management functions and expertise.
Participate in defining, maintaining, and interpreting care management standards of practice.
Assess and educate patients and families about community agencies and resources.
Educate and reinforce early identification of changes in patient condition and care transition plans.
Take responsibility for professional growth and share knowledge with coworkers and other healthcare providers.
Perform assigned work safely and follow departmental safety standards, rules, and practices; promptly report unsafe activities, conditions, hazards, or safety violations.
Maintain performance, patient-satisfaction, employee-satisfaction, and financial standards outlined in the performance evaluation.
Perform compliance requirements outlined in the Employee Handbook and adhere to DCH Behavioral Standards and Health System policies and procedures.
Perform essential job functions in a manner that promotes safety; identify and reduce unsafe practices and take appropriate action to reduce risks and hazards for patients, visitors, and employees.
Use electronic mail, time and attendance software, learning management software, and the intranet.
Perform other duties as assigned.