Hospital/LTC Case Manager
Job Title: Hospital/LTC Case Manager
Supervisor: LTC Director of Nurses
Pay Grade: DOE
Department/Division: Nursing Department
Works with residents, patients, their families, guardians, physicians, health care professionals and community resources, to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident or patient. Protect and advocate for the rights of residents and patients and ensure that the quality of care they receive meets all state and federal requirements. Provide admission and discharge planning services focused on continuity of care, resident/patient and family preferences and available resources.
- Record interventions, observations, assessments, and other important data, in the medical record.
- Maintain an organized, current case file system that reflects the needs of the residents and patients and the efforts made to meet those needs.
- Assist residents, patients and/or representatives with Medicaid applications and qualifications. Maintain a working knowledge of Medicare and Medicaid regulations and reimbursement processes.
- MDS REQUIREMENTS: Participates in MDS/RAI process for long term care and skilled nursing residents. Provides Minimum Data Set information and Care Area Assessment summaries for designated MDS sections. Honors established MDS/RAI timelines to meet regulatory requirements.
- Completes social histories for each resident at admission. Ensures that the residents comprehensive care plan and resident daily care plan include interventions that address social services needs.
- Assist new residents and their families in adjusting to life in the long term care setting.
- Be knowledgeable regarding State and Federal regulations for care management in critical access hospitals, and long term care facilities.
- Assess and identify the medically related psychosocial needs of residents and develop a plan of care to meet those needs.
- Develop at the time of admission and maintain an active discharge plan for each resident at the time of admission if applicable.
- Participate in multi-disciplinary care conferences and intra-agency meetings to facilitate treatment, needs assessment, and discharge planning,
- Arrange for and coordinate the discharge or transfer of appropriate residents or patients to their homes or other community placements, and appointments to assure continuity of care.
- Meet the psychosocial needs of residents and acute patients by providing short-term individual and/or family counseling, crisis intervention services, referral to outside resources and pertinent information as needed or directed.
- Serve as a liaison between LTC and Swing Bed residents and their families/relatives/guardians.
- Network with other facilities and social workers throughout the State of Alaska to facilitate admissions to our LTC and Swing Beds. Serve as the primary contact for referrals/admissions to CCMC; build and maintain relationships with other healthcare facilities to help increase referrals.
- Outreach and serves as a liaison between community members and needed services. The focus of this work is to connect community members with resources and services to assist with accessing primary care, behavioral health and core services including food, housing, clothing and other necessities.
- Core task focus will be on improving individual social determinants of health through:
- Develop plans of care to meet the needs of the client utilizing person-centered, strengths-based methods.
- Provide information about and linkage with available resources.
- Assist with Public Assistance, Unemployment, Social Security paperwork, and other application materials.
- Provide education and relevant printed materials on relevant health topics including Covid-19, vaccinations, preventative care, accessing health care.
- Work in collaboration with other team members and community providers to remove barriers to services: e.g., acquisition of identification, legal aid, benefits assistance, scheduling appointments, arranging transportation to appointments, enrollment with service providers.
- Actively participate in community meetings and consortiums relative to the provider network, collaborating effectively with coordinating service delivery.
- Is expected to respond to the hospital, if requested, to assist in the event of an emergency or if the hospital activates its emergency management plan.
The above is not intended to be an all-inclusive list of essential functions for the job described, but rather a general description of some of the responsibilities necessary to carry out the duties of this position.
Must possess, as a minimum, a bachelor’s degree must have case management and social services support experience.
Preferred, as a minimum, one (1) year experience in a medical setting.
The responsibilities for this position generally require a 25-hour work week. However, additional time may be necessary due to special events, crisis situations and/or unexpected demands of the caseload. Ability to effectively communicate in English, both orally and in writing. Ability to assess psychosocial behavior and medically related resident needs, and develop a meaningful plan of care, appropriate interventions, and effective discharge plans. Ability to effectively communicate with residents, families, other professionals, and the community, in a positive, professional manner. Ability to articulately express in writing, resident assessments, plans of care, and place these in the record in a timely manner as required by facility policy.
Upon date of Hire:
- Current Negative TB Test
- Ability to Pass a DHSS Criminal History Check and Drug Test
- Must be current in all immunizations
EQUAL EMPLOYMENT OPPORTUNITY
CCMC shall seek to insure and provide equal opportunity for all persons seeking employment without regard to race, age, color, religion, gender, marital
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CCMC employees benefit package includes the Alaska Public Employee Retirement System (PERS), Annual and Sick leave accrual, Group Health Insurance, Life Insurance and nine paid holidays.