Summary

Provides care management services to all patients and families to promote optimal functioning throughout the rehabilitation process. Maintains current with clinical practice through continuing education, research, and program development.

Essential Job Responsibilities

Provides care management services to patients and families. Provides an initial psychosocial assessment of patient and family functioning, adjustment to disability, health literacy status and coping skills. Provides education to facilitate adjustment, problem-solving, and the development/implementation of an appropriate discharge/transition plan. Communicate with patients and families/supports to promote participation in the development and execution of the plan of care. Acts as an internal case manager and functions as liaison with external case managers, providers, and funding sources to maximize patient satisfaction, quality, and cost-effective outcomes. Coordinates highly effective level of care transitions from inpatient to community-based levels of care and services, such as: outpatient rehabilitation, home care, hospice, school, vocational rehabilitation, counseling, etc. Oversees the patient follow-up process to insure highly durable outcomes. Documents patient/family status, progress and discharge status through initial evaluation, progress notes, and discharge summaries according to established time standards. Identify and remove barriers to the discharge/transition process by: Identifying complex discharge/transition needs early on in order to assist the patient and family/supports in acquiring resources, such as: non-covered medications, home modifications, non-funded equipment, etc. Ensuring access to all needed follow-up primary care and medications at discharge, which may include assistance in locating funding to reduce the likelihood of re-hospitalization. Educate patients and families/supports on current evidence-based practices related to complex /chronic disease management across the continuum of care to reduce the frequency of re-hospitalization. Communicates with rehabilitation team regarding patient and family needs, preferences, resources, funding issues and discharge/transition status in order to integrate the care process and minimize fragmentation in the services. Attends and participates actively in-patient team conferences by representing the needs, preferences and resources of the patient and family/supports. Identify the need for and facilitate family conferences as appropriate to assure the needs and preferences of the patient and family/supports are in unison with the goals and clinical interventions of the rehabilitation team. Functions as a patient advocate and maintains patient confidentiality. Educate the patient, the family/supports, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions can be made. Promote patient self-advocacy, choice, and self-determination. Educate patients and families/supports in the appropriate use of health care services. Improve quality of care and maintain cost-effectiveness on a case-by-case basis. Provides discipline specific coverage within the Mary Free Bed System as requested. Participates in orientation and training of new staff. Supervises student internships as appropriate. Supports program operations as assigned.

 

Leadership Must Haves will be followed for patient and staff interactions:

Rounding Thank You Notes Employee Selection/Peer Interviewing Key Words at Key Times AIDET® + Promise Standards of Behavior

 

Essential Job Qualifications

Possesses and demonstrates competence in an identified area of clinical expertise. Registered Nurse Current professional license with the State of Michigan in the area of practice is required Three years of experience as a care manager in a health care setting. Experience working in acute rehabilitation preferred. Excellent verbal and written communication skills, expressing self in a clear, concise, and professional manner. Ability to work collaboratively and effectively with the interdisciplinary team members and family. Excellent time management and organizational skills. Function in a self-directed manner. Ability to make quality, collaborative decisions in short timeframes. Analytical and strong problem-solving skills. Ability to work effectively and efficiently under tight deadlines, high volumes, and multiple interruptions.

Preferred Job Qualifications

Experience in interdisciplinary team management.

 

Physical Requirements:

Able to exert up to 10-20 pounds of force occasionally (up to 1/3 of the time) Able to lift, carry, push, pull, up to 10-20 pounds occasionally Able to sit for the majority of the time but may involve brief periods of time involving walking or standing. Able to use keyboard frequently (1/3 to 2/3 of the time)

 

Commitment to Diversity, Equity and Inclusion

Embrace Diversity, Equity, and Inclusion, by:

Treating everyone with dignity and respect Opening more doors to opportunities for underrepresented cultures Growing talent and people Evaluating and eliminating disparities Taking action against injustices, bias and racism Honoring our differences and how to collaborate Educating staff, patients, and the communities we care for Restoring Hope and Freedom, together

 

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.