Case Manager, Skilled Nursing Facility, PRN

Collaborative work environment with Brooks Rehabilitation medical staff on behalf of family & team members.

1. Interviews patients/families to obtain data regarding home environment, family relationships, financial resources, health and social histories, in order to address the comprehensive needs of the patients/families.  Demonstrates knowledge of age-specific needs in assessing family systems.

2. Orients patients/families to the rehab process and explores options regarding discharge planning, and the need for education and/or referral to community resources and support systems.

3. Provides various levels of case management services when indicated, e.g., emotional support to patients/families which facilitates adaptation to the disability and post rehab planning.

4. Relates a clear understanding of reimbursement/financial resources as applies to discharge planning, to include federal and state assistance programs such as Medicare and Medicaid.

5. Documents interventions and developments in the patient's medical record.  Records information in an accurate, timely, and concise manner.

6. Provides follow-up, ongoing monitoring, and intervention as needed to assume implementation of discharge plans, patient/family adjustment. 

7. Assists with program evaluation and quality assurance activities through follow-up questionnaires and/or other data.                                

8. Acts as a liaison between colleagues, other departments and community agencies.  Develops and maintains liaisons with local, state, and federal resources.

9. Acts as an advocate for patient rights, needs, and goals.  Seeks patient involvement in planning to the greatest extent possible.  Involves family/significant other when the patient cannot actively participate in goal setting.

10. Obtains written consent upon release of medical records.

11. Organizes individual workload and sets appropriate priorities based on patients' needs and departmental policies and standards.           

12. Fosters positive and professional relationships with patients, families, physicians, staff, and department peers.

13. Supports the interdisciplinary team process by formulating team conference reports and conferring with referral sources, patients, and families.     

14. Assumes responsibility for personal computer, various office supplies and equipment.

15. Applies Utilization Review (UR) criteria to assure appropriate continued stay and timely discharges.

16. Provides medical information, treatment plan, goals, and discharge planning to Quality Improvement Organization (QIO) as requested on appeals.                                 

17. Completes MDS Assessment and Care Plans.

18.

Review Advance Directives with patients/families and assist with implementation.

19.

Participate in care  planning for long term care residents and coordinate resources to address their car...