St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. Provides comprehensive care of patients admitted to the inpatient acute rehabilitation unit from admission through discharge. This includes securing coverage for services through continued stay reviews, retro authorizations and other coverage related efforts. The Case Manager actively explores and utilizes available internal and external resources to facilitate safe transitions from rehab, maximize quality of life beyond discharge, and reduce length of stay when appropriate. This includes assessing, planning, implementing, coordinating, and evaluating health and community related services to meet a patient’s physical, psychosocial, vocational, and health needs in a cost effective, outcomes-oriented, and timely manner. As department needs change, the services may be performed at any level within the Network’s continuum of services and/or sites. JOB DUTIES AND RESPONSIBILITIES: + Performs admission review on all rehabilitation patients that identifies psycho-social barriers, interventions to implement, and discharge planning needs to meet the desired goals for the next step in the continuum of care for the patient. + Completes an ongoing assessments of discharge planning needs, identifies and mitigates barriers, and proactively facilitates changes to ensure a safe, timely and efficient discharge. + Completes documentation + Facilitates resolution of issues surrounding patient care in a compassionate, empathetic manner. + Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis. + Collaborates with the patient, family, or other caregivers, and interdisciplinary team to design a discharge plan respective of the patient’s needs and goals. + Remain in contact with the patient/family at least three times per week to ensure the patient/family remains informed of the rehab process and discharge plans. + Participates in daily “stand-up” meetings with the interdisciplinary team to briefly review patient progress and provide updates on information relevant to the patient’s plan of care. + Participates in weekly Interdisciplinary Team Meetings for all patients which includes scheduling appropriate patients, completing documentation, and follow up with patients and families post meeting. + Arranges for services prior to discharge to meet patient’s needs both at time of discharge, reduce readmission, and maintain a healthy long-term outlook. This includes but is not limited to community, state, and federal resources and DME acquisition. + Provides appropriate assistance to complete medical paperwork. + Provides education to patient and families around issues related to adaptation to the patient’s diagnosis, illness, treatment, discharge plan and/or life situation. + Collaborates with outpatient Care Managers to identify patients for handover and post discharge follow-up. + Acts as a resource to the staff for coverage issues, discharge options, community resources, and regulatory issues regarding discharge planning and psychosocial processes. + Helps patients understand their rights regarding patient choice, medical treatment, advanced directives, and other related issues. + Maintains clinical records of all patient contact, clinical reviews, and interventions according to hospital policy and other regulatory guidelines (i.e. Medicare, CARF, JCAHO, etc.). Documentation is completed in a progressional and timely manner and includes interventions, recommendations, and referrals. + Facilitates authorizations, pre-certifications, concurrent reviews, and retro authorizations related to rehabilitation services and services pertinent to discharge planning. PHYSICAL AND SENSORY REQUIREMENTS: Sitting for up to 5 hours per day, 2 hours at a time. Standing for up to 1 hour per day, 1 hour at a time. Walking for up to 2 hours per day, 20 minutes at a time. Occasionally uses fingers to turn pages. Frequently uses hands to write, type, and hold charts. Rarely uses the hands or fingers for firm grasping or twisting/turning. Frequently uses upper extremities to lift and carry up to 10 pounds. Frequently stoops, occasionally squats, rarely reaches above shoulder level. Hearing as it relates to normal conversation in person or on telephone. Seeing as it relates to general vision, near vision, far vision, color vision, and peripheral vision. EDUCATION: MSW, RN (BSN preferred), OR Masters in a related field of physical, occupational, or speech therapy may be considered based upon experience and knowledge of care management and discharge planning. TRAINING AND EXPERIENCE: Preference is for at least two to five years of clinical experience in healthcare preferred, preferably in a rehabilitation hospital. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer. (http://www.slhn.org/EOE)