The Care Manager is involved in the coordination of care and services for patients who are identified as needing assistance or meeting Care Management criteria. The Care Manager is responsible for utilization review, utilization management, care coordination, and discharge planning. Information is gathered via an in-depth assessment that provides the healthcare team with the patientâ??s prior level of functioning, access to and/or use of community resources and available support systems. This information is used to assist the care team in developing a plan of care which includes, but is not limited to: assuring appropriateness of services and care setting, assuring individualized support and education, determining the need for continued services, planning for discharge, and identifying and connecting patients/families with available community resources if needed.
Actively fulfills Best in the Nation goals.
Assesses for appropriateness of level of care setting from admission through discharge.
Identifies patients requiring care management and takes the lead as care manager for those requiring intervention, especially with clinically complex cases.
Interviews patients and families to assess current functional status and support system.
Collaborates with the health care team to develop a plan of care by participating in patient care rounds.
Assures the discharge plan is in alignment with providing choice, assuring safety, and is timely and cost effective.
Assures the plan of care is individualized for patientâ??s with a chronic disease to support patient/family self management following discharge .
Facilitates the safe transfer of patients to alternate level of care settings, assuring appropriate exchange of information among all caregivers.
Assists with scheduling discharges, pre planning discharges and identifying discharge goals during patient care rounds to assist with patient flow on the units.
Helps to identify strategies for reducing length of stay and appropriate utilization of services.
Utilizes criteria including clinical pathway data and implements strategies to resolve controllable variances.
Assists in monitoring appropriate hospitalization and continued stays.
Provides education to other departments/floors regarding case management services and support, discharge planning and plan of care.
Serves as a support to social work partners in the area of medical necessity, discharge goals, Medicare criteria and disease management.
Attends and participates in department meetings and participates in multidisciplinary groups as necessary and/or requested.
Graduate of an accredited school of nursing
Minimum of three years clinical nursing experience
SCL Health is a faith-based, nonprofit healthcare organization that operates eight hospitals, four safety net clinics, one children’s mental health center and more than 190 ambulatory service centers in three states – Colorado, Kansas and Montana. The health system includes 15,000 full-time associates and more than 500 employed providers.