Social Worker job in Kingsville TX

Care Manager (CM) II

Job Description:

• The Care Manager (CM) II works in collaboration with the patient/family, physicians, and multidisciplinary team members to ensure patient progression through the continuum of care and to develop a plan of care for each assigned patient from admission through discharge.
• Responsible for identifying, initiating, and managing optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, and length of stay management.
• Support and expertise are provided through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs.
• Care Coordination and Discharge Planning are both responsibilities of this role.
• Assesses and responds to patient/family needs by coordinating efforts of other team members and identifies and resolves barriers that hinder effective patient care.
• Adheres to departmental and organizational goals, objectives, standards of performance, policies, and procedures, and continually assures regulatory compliance.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Coordinates the integration of case management functions into the patient care and discharge planning processes in collaboration with other hospital departments, external service organizations, agencies, and healthcare facilities.
• Coordinates/facilitates patient care progression throughout the continuum of care in an efficient and cost-effective manner.
• Serves as a resource, provides support, and advocates on behalf of the patient related to treatment decisions and end-of-life issues.
• Closely monitors patient length of stay in regard to the geometric mean length of stay and communicates/collaborates with appropriate interdisciplinary team members to remove barriers and expedite discharge.
• Implements and monitors the patient's plan of care to ensure effectiveness and appropriateness of services.
• Identifies and escalates local and system barriers that are impeding diagnostic or treatment progress and issues related to quality and risk as appropriate in a timely manner.
• Proactively identifies and resolves delays and obstacles to discharge.
• Uses advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Interviews patients/families to obtain information about social, emotional, and financial factors which impact health status to develop comprehensive discharge planning assessment and care plan.
• Assesses needs for discharge planning and continuing care/resource support following discharge; independently makes recommendations to patients and families regarding post-acute level of care needs and options.
• Initiates discharge planning at the time of admission and makes post-hospital service referrals based upon information gathered during assessment and interactions with physicians, multidisciplinary care team, and payors as indicated.
• Acts as a patient advocate by negotiating for, and coordinating, resources with payors, agencies, and vendors.
• Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Provides appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and the religious, developmental, health literacy, and educational backgrounds of the patient population.
• Assesses the patient's formal and informal support system as well as available benefits and/or community resources.
• Meets directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician.
• Ensures and maintains plan consensus from patient/family, physician, and payor.
• Provides education, information, direction, and support related to patient's goals of care.
• Acts as a patient advocate to develop treatment plans and coordinate patient care and to transition patients to the appropriate next level of care.
• Demonstrates and promotes respect for the dignity and rights of every patient while adhering to the safety standards and practices of the organization and the nursing profession.
• Collaborates with