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  PT Case Manager  - MERCY 

Actively supports Care Management plans and processes to measure, assess and improve quality, resource management, patient outcomes and Care Management metrics. 

  1. Reports      to Care Management leadership, the identification of avoidable days and      other Care Management measures including, but not limited, readmissions,      saved days, core measure monitoring, interventions, and delays, to ensure      data is accurately collected.
  2. Implements      strategies in collaboration with the healthcare team to reduce length of      stay (LOS) and resource utilization, never compromising quality or      outcomes.
  3. Ensures      patients are in the appropriate LOC according to evidenced based,      physician approved criteria and standards and prescribed plan of care
  4. Ensures      authorizations for post acute services are obtained in a timely manner
  5. Facilitates      denial management of post acute services 

Facilitates the discharge planning process to ensure patient throughput by (add) collaborating with the healthcare team.

  1. Prioritizes      patient’s need for Care Management services based on: target/high volume      Diagnosis-Related Group (DRG), high cost, outlier, LOS, frequent inpatient      admissions, unplanned readmission or significant variance.
  2. Identifies      risk factors for potential crisis intervention needs related to clinical      diagnosis, prognosis and/or patient/family dynamics.
  3. Identifies      and reports ethical situations to manager/supervisor and Ethics Committee      for resolution.
  4. Ensures      the multidisciplinary discharge plan is consistent with the patient’s      clinical course, continuing care needs and covered services. Evaluates on      an ongoing basis the patient’s status and progress toward reaching goals      set forth in the plan of care. 
  5. Supports      the patient/family decision regarding advance directives or verifying a      surrogate decision maker.
  6. Works      collaboratively to assess for clinical, spiritual, financial, educational,      functional and psychosocial baselines for patient/family to determine      appropriate and realistic outcomes.
  7. Educates      patient/family/support system on the plan of care and expected outcomes.      Improves patient/family understanding of and adjustment to the medical      diagnosis/prognosis or other care issues.

Emergency Department (ED) Care Management

  1. Identifies      target patient populations most likely to have discharge needs such as but      not limited to Primary Care Physician (PCP) Identifies Level of Care      (LOC) needs and facilitate discharge planning elderly, chronically ill,      underserved, limited or ineffective support system, polypharmacy issues,      no Primary Care Physician (PCP) Identifies Level of Care (LOC) needs and      facilitate discharge planning of appropriate patients treated ED;      thereby reducing ED re-visits or subsequent admissions.

2. Identifies the appropriate LOC (Inpatient, Outpatient Observation Stay) and collaborates with the attending Physician as indicated.

3. Identifies and provides community resources to ensure a safe transition of care. 

Communicates effectively and provides education.

  1. Collaborates      with patients, families and other members of the healthcare team to      facilitate care coordination.
  2. Handles      complaints/concerns in a prompt and courteous manner; assesses and directs      to appropriate person to deal with concerns as needed.
  3. Care      Manager provides patient and family education as it relates to discharge      plan.

Portrays a positive professional public image at all times.

  1. Consistently      works toward standards of excellence to continually improve personal      performance.
  2. Develops      professional relationships with community partners. 

Teamwork

  1. Builds      and maintains positive, professional relationships with the healthcare      team, placing organizational/team goals first.
  2. Assumes      responsibility, authority and accountability for assigned work, seeks to      assist team members and identifies opportunities for process improvements.

Technology

  1. Documents      data accurately in the electronic medical record and applicable programs      to ensure data for tracking and trending is accurate. 
  2. Maintains      technical knowledge and skills of computer and integrated software      systems.
  3. Maintains      current knowledge of online verification/ precertification process with      insurance carriers.

If applicable to care management facility:

Swing Bed Program

  • Maintains      established policies and procedures and updates them annually or as      needed.
  • Responsible      for evaluation of patient appropriateness for placement prior to admission      to Swing Bed status and appropriateness for continued rehab stay.
  • Provide      inservices as needed to the Medical/Surgical staff on subjects relating to      care of Swing Bed/LTC patients.
  • Responsible      for provision of Social Activities for Swing Bed Patients.
  • Works      with patients and families concerning optimal care of patient on the      continuum.

Provides Swing Bed patients with the Medicare Notice of Non-Coverage at least 2 days prior to discharge.

Other: Performs other duties as assigned

Office: 405-936-5626

Chanel.hisel@mercy.net

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