Work Shift:

Day (United States of America)

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview:

Complex Care Manager

JOB CODE:20101

FLSA Exemption Status: Non-Exempt

Telecommuting Eligible: Yes

SUMMARY (BASIC PURPOSE OF THE JOB)

Manages the needs of patients with complex issues by proactively identifying patients who have multiple or complex medical and/or psychosocial or family barriers that will prolong the acute care hospital stay. Responsible for the identification of the complicated social and financial factors and barriers to appropriate discharge. Assures patients are referred to all available, appropriate social and financial resources post discharge in order to transition patient efficiently and achieve the desired outcome.

MINIMUM REQUIREMENTS

Education: Master's degree in Social Work (MSW) or Registered Nurse (RN).

Experience: Three years experience in a clinical setting performing clinical social work or case management.

Other Credentials: AHA BLS - Healthcare Provider, Social Worker - Licensed

4 hours of Stroke related Continuing Education contact hours annually if assigned to: Critical Care, Intermediate Care Unit, Emergency Department, Neuro Units, Cardiology Inpatient at Hopewell, Peds ED, PACU, Interventional Radiology, CNI, Observation

Knowledge and Skills: Excellent communication, conflict management, organizational and planning skills

Special Training: Clinical training in a medical/clinical environment; knowledge of spreadsheet and word processing software, case management and patient information systems.

Usual Work Day:8 Hours  

REPORTING RELATIONSHIPS

Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS

• Documents clinical record, comprehensive assessment of patient needs including barriers to timely discharge, clinical interventions, support and appropriate community resources according to policy and utilizing recognized format, such as, assessment, intervention, and plan. Documents clinical record appropriate interventions including assessment, plans, and referrals in the discharge planning process.
• Documents in clinical record all referrals and clinical interventions related to abuse, neglect, domestic violence, alcohol and substance abuse, crisis intervention. Performs educational sessions for health care team related to abuse/neglect issues and reporting of same. Documents staff interventions in clinical record.
• Updates the health care team on the progress of managing the social and financial barriers that delay appropriate transitions during multidisciplinary rounds, length of stay meetings, and medical record documentation.
• Advocates for appropriate services for complex patients with payor and providers of post-acute care service, community service and other services in order to optimize patient outcome.
• Leads complex care rounds and organizes and participates in family meetings with providers and the multidisciplinary team to coordinate transition of care.
• Manages contract patients discharged from the hospital to ensure the post acute facility is working in the best interest of the patient and the hospital system.
• Prepares all documents for guardianship proceedings including investigator reports, medical and psychiatric notes and documents required from the legal department.
• Uses culturally competent skills to assess individual patient needs and refers to appropriate professional staff when necessary. Identifies barriers and plans for intervention to overcome or lessen barriers to achieve outcome as evidenced by treatment plan.
• Performs other duties as assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Standing , Walking , Carry objects , Keyboard use/repetitive motion

Occasional physical demands include: Sitting , Climbing (e.g., stairs or ladders) , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation , Pinching/fine motor activities

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