Care Manager

Job description

Overview The Care Manager works collaboratively with interdisciplinary and healthcare team members, both internal and external to the organization to facilitate patient care through effective utilization and monitoring of healthcare resources and assumes a leadership role to achieve safe discharge planning along with desired clinical and financial outcomes. The Care Manager coordinates care and services through the acute care episode and across the continuum. Responsibilities: Assessment: - Completes a face to face assessment of all new patients in caseload within 24 hours or next business day to identify appropriateness for acute care, level of care and to anticipate high level care planning needs. Screens high risk patients with lace score greater than or equal to 10 to reduce 30 day readmissions. Consults with attending physicians regarding potential care transition barriers identified as a result of this process. - Assumes transition process in collaboration with the multidisciplinary team and patient/family and assists with executing the plans and interventions to facilitate the stay and manage the length of stay. - Facilitates patient care conferences/complex case conferences...