The Case Manager functions under the direct supervision of the Transitions of Care Manager. The Case Manager in collaboration with other disciplines, physicians, patients and families, assumes a leadership role in coordinating and monitoring the process of care, quality outcomes, and resources utilized across the continuum. The Case Manager expedites value added interventions to achieve desired outcomes and offer credible alternatives to prevent unnecessary admissions to the hospital. Proactively guiding patients to the right care at the right time and the right place. Qualifications: + Education + Graduate of an accredited RN program. + BSN preferred + Certification/Licensure + Current RN or multi-state RN license + Nationally recognized certification Hospice and Palliative care + Experience + At least two (2) years in a health care environment + Previous experience in hospital case management and infection control preferred + Specialized Training + Basic coding; working knowledge of case management, discharge planning. + Computer Skills + Proficient with Microsoft Office. Job Duties and Standards + Clinically assesses and screens 100% of assigned caseload. Interviews, researches, and gathers data to identify patient's needs to formulate a plan of care in collaboration with the patient, family, physician and other disciplines. This plan encompasses both long and short-term goals to maximize treatment and services in a cost effective and proactive manner across the continuum. The case manager is a consistent resource throughout the continuum of care. + Reviews and monitors patients daily for appropriate level of care, use of resources, quality of care based on severity of illness/intensity of services. Effectively interfaces with case managers from external insurance carriers. Communicates with payers to avoid financial risk to patient. Coordinates and negotiates resources to meet the needs of patients per clinical guidelines. + When needed makes home visits to do a physical assessment, medication reconciliation, assess the home environment and assist in virtual visits under the direction of a provider. + Set up, utilize and monitor at home devices. Provides education and communicates with the provider based on approved parameters. + Evaluates effectiveness of previous assessments and care plans for patient with readmission or frequent admissions for the same illness; implements care plan modifications to reach desired outcomes and goals. + Accurately collects data on quality indicators, statistics, and other identified outcome measures. + Provides educational and resource support to physicians and other healthcare providers in identification of alternative healthcare options. + Assumes a leadership role to ensure communication and collaboration among all team members and disciplines to improve patient outcomes through out the continuum of care. + Conducts consults within the hospital and clinics and when appropriate bills for + Counseling and support for patients and families + Advance care planning (living will, MOST form, HCPOA discussions) + Care coordination – in the context of chronic care management, transitional care management and navigation. + Referrals to appropriate interdisciplinary services to enhance function and/or quality of life (i.e., cancer rehab, psychotherapy/counseling, psychiatry, integrative medicine, geriatrics, hospice etc.) + Age Specific Competency: Staff members will have knowledge of human growth and development through the life span of the patient and have the ability to meet the needs of and provide the care of these patients. The age categories to be included are: Neonatal/Infant 0 - 11 months; Pediatrics 1 – 12 yrs; Adolescence 13 - 17 yrs; Young Adult/Adult 18 – 64 yrs; Adult/Middle-Aged 65 - 79 yrs; Geriatric 80+ yrs + Performs other related duties or special projects as may be assigned