Case Manager

Provides reassurance on the phone to patients and families. Assists in finding solutions to their questions and/or recognizes the need for an in person visit. Coordinates in person visit when needed/or requested.
Utilizes appropriate support/expert resources or personnel to resolve complex or difficult situations.
Documents patient/family contact information in the EMR and communicates with the Interdisciplinary Team (IDT).
Completes initial and semi-annual assessment for all Company services including, but not limited to:
Explains services to patients/families and addresses questions regarding patient needs, fears, physical limitations, while putting the patient/family at ease; presents services in an empathetic and compassionate manner 
Provides information to Physicians and other IDT members and initiates Plan of Care to address patient’s immediate needs
Initiates skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms and maximize physical and emotional comfort
Obtains Physician orders
Completes documentation per Company policy
Acts as the Company representative at assigned facilities while facilitating referrals to all service lines; works closely with referring hospitals, physicians, facilities, patients, families, and the general public.
Communicates frequently with other members of the IDT.
Provides all necessary clinical communication timely using SBAR.
Discusses any potential needs with after-hours staff.
Develops strong relationships with case managers, physicians, etc. at facilities.

Competencies:
• Satisfactorily complete competency requirements for this position.

Responsibilities of all employees:
• Represent the Company professionally at all times through care delivered and/or services provided to all clients.
• Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
• Comply with Company policies, procedures and standard practices.
• Observe the Company's health, safety and security practices.
• Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
• Use resources in a fiscally responsible manner.
• Promote the Company through participation in community and professional organizations.
• Participate proactively in improving performance at the organizational, departmental and individual levels.
• Improve own professional knowledge and skill level.
• Advance electronic media skills.
• Support Company research and educational activities.
• Share expertise with co-workers both formally and informally.
• Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.

Job Responsibilities:
• Provides and manages direct care to patients and families as part of Interdisciplinary Team (IDT), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up.
• Coordinates the Plan of Care, ensuring that an individualized Plan of Care is developed that accurately reflects the patient’s evolving needs.
• Educates patient, family, caregivers and other health professionals about disease process and decline, prevention, palliative interventions, care giving, dying process and safety practices.

- Participant visit frequency dependent on risk score/needs to be determined

- Home visits to assess home safety, medication compliance, nutritional compliance, DME compliance- ability to live safely in the community.
• Reports changes in the patient’s condition to appropriate members of the IDT or other health professionals.
• Participates with the IDT to evaluate hospice referrals/admissions for level of care appropriateness.

- Attends daily IDT collaboration meetings
• Presents concise and pertinent oral and written reports to IDT; respects and encourages input from all disciplines.
• Communicates accurately and completely to physicians, staff members, patients, families, and supervisors; utilizes positive approaches when working with others.
• Supervises patient care provided by Community Health Workers and Home Health Aides as requested.

• During times of emergencies (i.e. Hurricanes, etc.), the RN, Case Manager may be required to report to work at a location designated by the company, to ensure continuity of services. This may include reporting to work ahead of your scheduled date/time due to planned lock down of unit, and staying overnight(s) based on duration of emergency.
• Performs other duties as assigned.

Physical Demands for Post Offer/Pre-Placement (The demands described below are representative of those that must be met by an individual to perform the essential functions of the job, with or without reasonable accommodation.):

While performing the duties of this job, the following abilities are required: see; hear; talk; walk; use hands to finger, handle or feel.

Frequently required to: stand; sit; reach with hands/arms; lift; bend; balance.

Occasionally required to: pull; push; stoop/crouch; kneel; climb stairs.