Case Manager (RN) - Stanyan

The Case Manager coordinates resources and services in response to individual patient's needs and fiscal realities, performs utilization review activities and oversees coordination of complex discharge planning for assigned case load. The Case Manager is an active member of the interdisciplinary team contributing to team goal setting. The Case Manager acts as a consultant to the clinical team, service lines and other departments and participates in program development and quality improvement initiatives.

The Case Manager provides age-appropriate assessments, interpretation of data, and delivery of interventions. Demonstrates the ability to work with any patient regardless of race, gender, religious affiliation, cultural beliefs, lifestyle, and disease process or treatment plan.

The Case Manager provides a day-to-day leadership support for the team. In addition to assessing patients, developing transition plans, facilitating safe and timely discharges, and collaborating with the multidisciplinary team, this role assists with leading daily huddles and Multidisciplinary Rounds conducting complex case reviews, support quality and documentation audits, and helping manage daily departmental operations.

Required Qualifications:

• Possesses a Bachelor''s Degree in Nursing
• Minimum of two (2) years of previous healthcare related experience
• One (1) year of case management experience
• Knowledge and abilities are essential to the successful performance of the duties assigned to the position.
• Demonstrate resourcefulness, superior written and oral communication, diplomacy, organizational and analytic skills.
• Self-directed, assertive and creative in problem solving, systems planning and patient care management in a high-volume work environment.
• Basic computer skills and proficiency with an electronic patient record
• Ability to work effectively and collaboratively with interdisciplinary teams
• This position requires flexibility to orient and work at all UCSF Medical Center locations

Preferred Qualifications:

• Recent experience in Case Management, utilization review or discharge planning
• Master''s Degree in Nursing or a healthcare-related field
• CCM or ACM

Required License/Certifications:

• Active CA Registered Nurse license

DUTIES & ESSENTIAL JOB FUNCTIONS

The Case Manager coordinates resources and services in response to individual patient's needs and fiscal realities, performs utilization review activities and oversees coordination of complex discharge planning for assigned case load. The Case Manager is an active member of the interdisciplinary team contributing to team goal setting. The Case Manager acts as a consultant to the clinical team, service lines and other departments and participates in program development and quality improvement initiatives.

The Case Manager provides age-appropriate assessments, interpretation of data, and delivery of interventions. Demonstrates the ability to work with any patient regardless of race, gender, religious affiliation, cultural beliefs, lifestyle, and disease process or treatment plan.

The Case Manger provides a day-to-day leadership support for the team. In addition to assessing patients, developing transition plans, facilitating safe and timely discharges, and collaborating with the multidisciplinary team, this role assists with leading daily huddles and Multidisciplinary Rounds conducting complex case reviews, support quality and documentation audits, and helping manage daily departmental operations.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

40

YES

• The Case Manger provides a day-to-day team lead support for the team. In addition to assessing patients, developing transition plans, facilitating safe and timely discharges, and collaborating with the multidisciplinary team, this role assists with leading daily huddles and Multidisciplinary Rounds, conducting complex case reviews, support quality and documentation audits, and helping manage daily departmental operations.

• Work in a collaborative practice model, facilitating care coordination with the multidisciplinary treatment team for care progression to optimize patient outcomes and timely discharge when patient is deemed medically ready.

• Provide case management assessment and interventions based on initial screening for discharge needs, identify readmission risks, patient strengths and needs related to transition and discharge planning; collaborate and communicate with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, ongoing evaluation, and medical readiness for discharge. Maintain a reduced or adjusted caseload as needed to fulfill leadership and operational support responsibilities.

• Oversee and support complex medical discharge planning needs for assigned patients in collaboration with other interdisciplinary team members, assuring a safe discharge plan is developed and implemented in a timely manner; proactively identifies and resolves delays and obstacles to discharge.

• Collaborate with providers and all members of the multi-disciplinary team to manage the clinical resources and transition planning for patients within assigned caseload from admission through discharge, actively working to identify/eliminate barriers to deliver of services required to advance care and promote timely discharge based on medical readiness; facilitate the following on a timely basis:

• Completion and reporting diagnostic testing,

• Completion of discharge plan,

• Modification of plan of care, as necessary, to meet the ongoing needs of patient,

• Completion of all required documentation in APeX flowsheets and patient records

• Coordinate and lead multi-disciplinary rounds (MDRs) and monitor discharge milestones, assign accountability for tasks, and proactively identify and address/ escalate barriers to timely discharge when medically ready.

15

YES

• Ensure that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Consider age specific needs of the patient as appropriate and effectively communicates and interacts with patients, families, staff and members of the community from diverse backgrounds.

15

YES

• Refer appropriate cases for social work intervention

• For patients with significant or intensive psychosocial needs, serve as the secondary care manager, working in close collaboration with the social worker to bring nursing scope of practice and expertise to address the holistic needs of the patient.

15

YES

• Monitor patients' length of stay and collaborates with physicians to ensure resource utilization remains within covered benefits and are appropriate in relationship to the patient's clinical and psychosocial needs.

• Initiate and facilitate referrals through the Resource Coordinators for post-acute care resources (i.e. home health care, SNF, rehab facilities, hospice, medical equipment and supplies).

• Oversee and direct activities delegated and performed by the Resource Coordinator and/or Patient Care Navigator.

10

YES

• Participate in clinical performance/quality improvement teams within the department, service lines, and hospital to identify opportunities for improvement in such areas as clinical outcomes, length of stay management, and utilization of resources; use data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.

• Provide consultation and education to members of the healthcare team, hospital departments, service lines and community agencies and providers.

• Initiate and lead the development, implementation, evaluation and revision of clinical pathways and other case management tools as a member of the clinical resource/team.

• Participate in department program planning including goal setting, program development, systems development and improvement. Participates on department and hospital committees and task forces

5

YES

• Demonstrate competency with work-required computer programs and incorporates use into daily work routine.

Demonstrate the ability to interpret data and trends using appropriate analytical skills.

100%

LIVING PRIDE STANDARDS

Service Excellence

• Demonstrates service excellence by following the Everyday PRIDE Guide with the UCSF Medical Center standards and expectations for communication and behavior. These standards and expectations convey specific behavior associated with the Medical Center's values: Professionalism, Respect, Integrity, Diversity and Excellence, and provide guidance on how we communicate with patients, visitors, faculty, staff, and students, virtually everyone, every day and with every encounter. These standards include, but are not limited to: personal appearance, acknowledging and greeting all patients and families, introductions using AIDET, managing up, service recovery, managing delays and expectations, phone standards, electronic communication, team work, cultural sensitivity and competency.

• Uses effective communication skills with patients and staff; demonstrates proper telephone techniques and etiquette; acts as an escort to any patient or family member needing directions; shows sensitivity to differences of culture; demonstrates a positive and supportive manner in which patients / families/ colleagues perceive interactions as positive and supportive. Exhibits team work skills to positively acknowledge and recognize other colleagues, and uses personal experiences to model and teach Living PRIDE standards.

• Exhibits tact and professionalism in difficult situations according to PRIDE Values and Practices

• Demonstrates an understanding of and adheres to privacy, confidentiality, and security policies and procedures related to Protected Health Information (PHI) or other sensitive and personal information.

• Demonstrates an understanding of and adheres to safety and infection control policies and procedures.

• Assumes accountability for improving quality metrics associated with department/unit and meeting organizational/departmental targets.

Work Environment

• Keeps working areas neat, orderly and clutter-free, including the hallways. Adheres to cleaning processes and puts things back where they belong. Removes and reports broken equipment and furniture.

• Picks up and disposes of any litter found throughout entire facility.

• Posts flyers and posters in designated areas only; does not post on walls, doors or windows.

• Knows where the Environment of Care Manual is kept in department; corrects or reports unsafe conditions to the appropriate departments.

• Protects the physical environment and equipment from damage and theft.

OTHER FUNCTIONS AND RESPONSIBILITIEs

• Performs other duties as assigned.

POPULATIONS SERVED

Adult

Geriatric

DUTIES & ESSENTIAL JOB FUNCTIONS

The Case Manager coordinates resources and services in response to individual patient's needs and fiscal realities, performs utilization review activities and oversees coordination of complex discharge planning for assigned case load. The Case Manager is an active member of the interdisciplinary team contributing to team goal setting. The Case Manager acts as a consultant to the clinical team, service lines and other departments and participates in program development and quality improvement initiatives.

The Case Manager provides age-appropriate assessments, interpretation of data, and delivery of interventions. Demonstrates the ability to work with any patient regardless of race, gender, religious affiliation, cultural beliefs, lifestyle, and disease process or treatment plan.

The Case Manger provides a day-to-day leadership support for the team. In addition to assessing patients, developing transition plans, facilitating safe and timely discharges, and collaborating with the multidisciplinary team, this role assists with leading daily huddles and Multidisciplinary Rounds conducting complex case reviews, support quality and documentation audits, and helping manage daily departmental operations.

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

40

YES

• The Case Manger provides a day-to-day team lead support for the team. In addition to assessing patients, developing transition plans, facilitating safe and timely discharges, and collaborating with the multidisciplinary team, this role assists with leading daily huddles and Multidisciplinary Rounds, conducting complex case reviews, support quality and documentation audits, and helping manage daily departmental operations.

• Work in a collaborative practice model, facilitating care coordination with the multidisciplinary treatment team for care progression to optimize patient outcomes and timely discharge when patient is deemed medically ready.

• Provide case management assessment and interventions based on initial screening for discharge needs, identify readmission risks, patient strengths and needs related to transition and discharge planning; collaborate and communicate with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, ongoing evaluation, and medical readiness for discharge. Maintain a reduced or adjusted caseload as needed to fulfill leadership and operational support responsibilities.

• Oversee and support complex medical discharge planning needs for assigned patients in collaboration with other interdisciplinary team members, assuring a safe discharge plan is developed and implemented in a timely manner; proactively identifies and resolves delays and obstacles to discharge.

• Collaborate with providers and all members of the multi-disciplinary team to manage the clinical resources and transition planning for patients within assigned caseload from admission through discharge, actively working to identify/eliminate barriers to deliver of services required to advance care and promote timely discharge based on medical readiness; facilitate the following on a timely basis:

• Completion and reporting diagnostic testing,

• Completion of discharge plan,

• Modification of plan of care, as necessary, to meet the ongoing needs of patient,

• Completion of all required documentation in APeX flowsheets and patient records

• Coordinate and lead multi-disciplinary rounds (MDRs) and monitor discharge milestones, assign accountability for tasks, and proactively identify and address/ escalate barriers to timely discharge when medically ready.

15

YES

• Ensure that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Consider age specific needs of the patient as appropriate and effectively communicates and interacts with patients, families, staff and members of the community from diverse backgrounds.

15

YES

• Refer appropriate cases for social work intervention

• For patients with significant or intensive psychosocial needs, serve as the secondary care manager, working in close collaboration with the social worker to bring nursing scope of practice and expertise to address the holistic needs of the patient.

15

YES

• Monitor patients' length of stay and collaborates with physicians to ensure resource utilization remains within covered benefits and are appropriate in relationship to the patient's clinical and psychosocial needs.

• Initiate and facilitate referrals through the Resource Coordinators for post-acute care resources (i.e. home health care, SNF, rehab facilities, hospice, medical equipment and supplies).

• Oversee and direct activities delegated and performed by the Resource Coordinator and/or Patient Care Navigator.

10

YES

• Participate in clinical performance/quality improvement teams within the department, service lines, and hospital to identify opportunities for improvement in such areas as clinical outcomes, length of stay management, and utilization of resources; use data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.

• Provide consultation and education to members of the healthcare team, hospital departments, service lines and community agencies and providers.

• Initiate and lead the development, implementation, evaluation and revision of clinical pathways and other case management tools as a member of the clinical resource/team.

• Participate in department program planning including goal setting, program development, systems development and improvement. Participates on department and hospital committees and task forces

5

YES

• Demonstrate competency with work-required computer programs and incorporates use into daily work routine.

Demonstrate the ability to interpret data and trends using appropriate analytical skills.

100%

LIVING PRIDE STANDARDS

Service Excellence

• Demonstrates service excellence by following the Everyday PRIDE Guide with the UCSF Medical Center standards and expectations for communication and behavior. These standards and expectations convey specific behavior associated with the Medical Center's values: Professionalism, Respect, Integrity, Diversity and Excellence, and provide guidance on how we communicate with patients, visitors, faculty, staff, and students, virtually everyone, every day and with every encounter. These standards include, but are not limited to: personal appearance, acknowledging and greeting all patients and families, introductions using AIDET, managing up, service recovery, managing delays and expectations, phone standards, electronic communication, team work, cultural sensitivity and competency.

• Uses effective communication skills with patients and staff; demonstrates proper telephone techniques and etiquette; acts as an escort to any patient or family member needing directions; shows sensitivity to differences of culture; demonstrates a positive and supportive manner in which patients / families/ colleagues perceive interactions as positive and supportive. Exhibits team work skills to positively acknowledge and recognize other colleagues, and uses personal experiences to model and teach Living PRIDE standards.

• Exhibits tact and professionalism in difficult situations according to PRIDE Values and Practices

• Demonstrates an understanding of and adheres to privacy, confidentiality, and security policies and procedures related to Protected Health Information (PHI) or other sensitive and personal information.

• Demonstrates an understanding of and adheres to safety and infection control policies and procedures.

• Assumes accountability for improving quality metrics associated with department/unit and meeting organizational/departmental targets.

Work Environment

• Keeps working areas neat, orderly and clutter-free, including the hallways. Adheres to cleaning processes and puts things back where they belong. Removes and reports broken equipment and furniture.

• Picks up and disposes of any litter found throughout entire facility.

• Posts flyers and posters in designated areas only; does not post on walls, doors or windows.

• Knows where the Environment of Care Manual is kept in department; corrects or reports unsafe conditions to the appropriate departments.

• Protects the physical environment and equipment from damage and theft.

OTHER FUNCTIONS AND RESPONSIBILITIEs

• Performs other duties as assigned.

POPULATIONS SERVED

Adult

Geriatric