| Location | Carson City, NV |
US:NV:Carson City Case Management
Per Diem Day Shift
Summary
This individual is responsible to facilitate care through the continuum utilizing effective resource coordination to promote optimal access to care balancing the patients' resources and right to self-determination
The overall responsibility to assess the patient for transition of care needs and risk for readmission
This individual will be able to conduct complex psycho-social assessments and provide interventions to assist with throughput, safe discharges and avoid readmissions
Has focus on complex social and post-acute care services
Qualifications
Required:
Preferred:
Two (2) years of acute care coordination experience
Ability to obtain Accredited Case Manager (ACM) certification
Essential Functions
Transition Management
Completes initial /comprehensive assessment within 24 hours of admission, including anticipated transition (discharge) plan
Provides psycho-social assessment and intervention for patients identified with behavioral health issues, lack of social support systems, financial barriers, end of life and plan of care adherence
Ensures plan of care and interventions are implemented and communicated to health care team, patient/family and post-acute care providers
Complete timely, accurate and concise documentation in the Electronic Medical Record
Care Coordination
Screens high risk and referred patients for psycho-social issues/barriers, that may impact the transition plan and intervenes as appropriate
Assists with adoption/abuse/neglect cases and reports to appropriate external agencies as required
Collaborates with patient/family/health care team to ensure patient preferences and choices are taken into consideration within the limitations of available resources
Education
Ensure patient/ family receive education appropriate to their specific discharge plan
Provides education to medical and nursing staff regarding relevant issues related to transition plan
Precepts new staff members and acts as resource to all staff
Compliance
Ensures compliance with local, state and federal regulations and accreditation requirements
Operates within social work scope of practice as defined by the state licensing board
Participates in department Quality improvement initiatives
Complex Case Management
Completes clear, concise and accurate initial/discharge planning/complex psycho-social assessments and reassessments per departmental guidelines (assessments within 24 hours of admission, reassessments every 3 days or as needed for change)
Escalates barriers to transition planning per departmental escalation plan
Completes post-acute referrals within 3 days of admission
Schedules and facilitates complex case patient/family conferences as needed (at a minimum of weekly)
Performs other related duties as assigned.