Clinical Case Manager- 36hrs

The Case Manager is responsible for coordinating and facilitating high-quality, patient-centered care across the continuum of services. Through early identification and assessment of patient needs, the Case Manager collaborates with patients, families, providers, and interdisciplinary team members to develop and implement effective care plans. As a key member of the healthcare team, the Case Manager promotes timely access to services, supports care transitions, addresses barriers to care, and helps optimize patient outcomes while ensuring efficient utilization of healthcare resources.

The Case Manager plays an integral role in discharge planning by proactively identifying patient needs, coordinating post-acute services, and facilitating safe and timely transitions of care. Through collaboration with the interdisciplinary team, the Case Manager works to improve patient outcomes, reduce readmission risk, minimize avoidable days, and ensure patients receive the appropriate level of care throughout their healthcare journey.

Patient Assessment, Care Planning & Care Coordination-45%

• Conduct comprehensive assessments to identify patient, family, and caregiver needs, including medical, psychosocial, financial, and environmental factors.
• Develop, implement, and monitor individualized care plans in collaboration with patients, families, providers, and interdisciplinary team members.
• Coordinate care and services across the continuum, including inpatient, outpatient, community-based, and specialty care settings.
• Facilitate timely referrals to internal and external resources, programs, and community agencies.
• Support care transitions and discharge planning to ensure continuity of care and reduce barriers to treatment.
• Monitor patient progress toward established goals and modify care plans as needed.
• Advocate for patients and families to promote access to appropriate healthcare services and resources.

Patient, Family & Community Engagement-25%

• Educate patients and families regarding diagnoses, treatment plans, available resources, and self-management strategies.
• Collaborate with physicians, nurses, social workers, therapists, and other healthcare professionals to optimize patient outcomes.
• Identify and address barriers to care, including social determinants of health that may impact treatment adherence and health outcomes.
• Serve as a resource and liaison for patients, families, providers, and community partners regarding care coordination services.
• Promote patient and family engagement in care planning and goal setting.
• Foster partnerships with community organizations and service providers to improve access to care and support.

Documentation, Quality & Population Health Management-25%

• Maintain accurate, timely, and complete documentation in accordance with organizational, regulatory, and payer requirements.
• Participate in quality improvement initiatives, care management programs, and performance metrics related to patient outcomes and resource utilization.
• Ensure compliance with organizational policies, accreditation standards, and applicable federal and state regulations.
• Utilize data and population health tools to identify high-risk patients and support proactive care management interventions.
• Monitor care coordination outcomes and contribute to organizational performance improvement efforts.

Administrative & Other Duties-5%

• Monitor care coordination outcomes and contribute to organizational performance improvement efforts.
• Attend departmental meetings, training sessions, and professional development activities. 
• Participate in organizational initiatives and special projects as assigned.
• Performs other job-related duties as assigned.

Education and/or Experience Required:

• Education: BSN Required.
• Experience: At least 3 yrs. experience in a healthcare setting required.

Education and/or Experience Preferred:

• Experience: Pediatrics, Case Management, Discharge Planning preferred.

License and/or Certification Required:

• Current State of Connecticut Registered Nurse licensure.

License and/or Certification Preferred:

• Case Management Certification.

Knowledge, Skills and Abilities:

Knowledge:

• Demonstrates working knowledge of clinical care management principles, utilization management practices, and the interpretation and application of medical necessity and level-of-care criteria.
• Knowledge of healthcare delivery systems, discharge planning processes, care transitions, and interdisciplinary