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PRN Case Manager - Transition Support Post Discharge

Shepherd Center

Atlanta, Georgia

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JOB DETAILS
SKILLS
Academic Advice, Case Management, Cerebral Vascular Accident, Clinical Medicine, Clinical Research, Communication Skills, Customer Support/Service, Discharge Plans, Documentation, Electronic Medical Records, Follow Through, Hospital, Intensive Care, Leadership, Maintain Compliance, Medical Treatment, Medications, Multiple Sclerosis, Neurotrauma (Traumatic Brain Injury), Nursing, Organizational Skills, Patient Education, Problem Solving Skills, Registered Nurse (RN), Regulatory Compliance, Regulatory Requirements, Risk, Risk Analysis, Safety/Work Safety, Spinal Cord Injury, Team Player, Telephone Skills, Training/Teaching, Treatment Plan
LOCATION
Atlanta, Georgia
POSTED
2 days ago
About Shepherd Center

With five decades of experience, Shepherd Center provides world-class clinical care, research, and family support for people experiencing the most complex conditions, including spinal cord and brain injuries, multi-trauma, traumatic amputations, stroke, multiple sclerosis, and pain. An elite center ranked by" U.S. News "as one of the nation's top hospitals for rehabilitation, Shepherd Center is also recognized as both Spinal Cord Injury and Traumatic Brain Injury Model Systems. Shepherd is the only rehabilitation facility in the nation with an intensive care unit on-site, allowing us to care for the most complex patients and begin the rehabilitation process sooner. Shepherd Center treats thousands of patients annually with unmatched expertise and unwavering compassion to help them begin again.

Shepherd Center's culture is one of hope, humor, and hard work. You will enjoy career growth, strong relationships with co-workers , strong support from leadership, and fun activities that have ke pt over 1 2% of staff members working at Shepherd for more than 20 years .

Transition Support Case Management (TSP CM) is a collaborative process performing the primary role functions of assessment, planning, facilitation, and advocacy for options and services to meet a patient's health needs post discharge. Responsibilities include assisting the client and/or family caregivers with follow through of discharge plan and homecare instructions to prevent rehospitalization. In this role, the TSP CM empowers patients and their families towards greater autonomy and improved health and safety outcomes post discharge. The TSP CM will serve all high-risk medical clients including, but not limited to, vent dependent clients and clients with disorders of consciousness. This process requires an organized individual with excellent communication skills.

Job Responsibilities:
  • The TSP Case Manager is an integral part of a patient's recovery process, helping to continue coordinating the efforts began by the interdisciplinary rehabilitation team. Job Functions:
  • Attends interdisciplinary team meetings and identifies patients who qualify for the Transition Support Program.
  • Collects thorough and accurate chart review prior to discharge home via EMR review
  • Collaborates with interdisciplinary team and obtains report from referring CM and primary RN.
  • Meets with the client/family prior to discharge to explain the role and function of Transition Support services.
  • Work closely with client's physicians to address needs/concerns (medical needs, therapy goals, vocational interests/goals, and patient financial status, etc.) as they arise.
  • TSP CM calls every client/family at a minimum of once a week and is available throughout the week to answer unlimited calls and emails from client/family.
  • Develops a mutually acceptable plan of care to maximize health and safety goals.
  • Helps facilitate community re-entry and assists clients/caregivers in locating community-based resources.
  • Assists with the identification of financial grants/waivers and assists with the completion of applications.
  • Continues the coordination of physician orders to outside suppliers.
  • Manages requests for medication assistance and completes other required forms and letters.
  • Identifies patient and family education needs and provides necessary re-education.
  • Provides ongoing education, guidance, and support post discharge, with a strong focus on medical, financial, and psychosocial needs.
  • Assist clients and caregivers in determining personal goals that lead towards improved long-term health and a meaningful life post injury.
  • Completes thorough and accurate documentation in electronic records.
  • Practices proper safety techniques in accordance with Center and departmental policies and procedures. Responsible for the reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.
  • Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility. Identifies potential risk areas within area of responsibility and supports problem resolution process.
Required Minimum Education:
  • Bachelor's degree in Nursing
Required Minimum Certifications:
  • CCM required within 2 years.
Required Licensure:
  • Active Georgia RN license or NLC/eNLC Multistate License.
Required Minimum Experience:
  • A minimum of at least 5 ye

About the Company

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Shepherd Center

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