Care Manager - Inpatient

Employment Type 
Full-time

Days Worked 
Monday - Friday
Hours: 
40 hrs/week, Salaried/Exempt.
Primary Location 
Main Hospital - Grand Rapids, MI 
Department Name 
Care Management
Other Benefits: 
Annual Merit Increases, Health Insurance (Medical, Dental, Vision,) PTO, Holiday Pay, PSLF Eligible, Tuition Reimbursement

Summary    

Provides care management services to all patients and families to promote optimal functioning throughout the rehabilitation process.  Maintains current with clinical practice through continuing education, research, and program development.

Essential Job Responsibilities                                                   

• Provides care management services to patients and families.
• Provides an initial psychosocial assessment of patient and family functioning, adjustment to disability, health literacy status and coping skills.
• Provides education to facilitate adjustment, problem solving, and the development/implementation of an appropriate discharge/transition plan.
• Communicate with patients and families/supports to promote participation in the development and execution of the plan of care.
• Acts as an internal case manager and functions as liaison with external case managers, providers and funding sources to maximize patient satisfaction, quality, and cost-effective outcomes.
• Coordinates highly effective level of care transitions from inpatient to community-based levels of care and services, such as: outpatient rehabilitation, home care, hospice, school, vocational rehabilitation, counseling, etc.
• Oversees the patient follow up process to insure highly durable outcomes.
• Documents patient/family status, progress and discharge status through initial evaluation, progress notes, and discharge summaries according to established time standards.
• Identify and remove barriers to the discharge/transition process by:
• Identifying complex discharge/transition needs early on in order to assist the patient and family/supports in acquiring resources, such as: non-covered medications, home modifications, non-funded equipment, etc.
• Ensuring access to all needed follow-up primary care and medications at discharge, which may include assistance in locating funding to reduce the likelihood of re-hospitalization.
• Educate patients and families/supports on current evidence based practices related to complex /chronic disease management across the continuum of care to reduce the frequency of re-hospitalization.
• Communicates with rehabilitation team regarding patient and family needs, preferences, resources, funding issues and discharge/transition status in order to integrate the care process and minimize fragmentation in the services.
• Attends and participates actively in-patient team conferences by representing the needs, preferences and resources of the patient and family/supports. Identify the need for and facilitate family conferences as appropriate to assure the needs and preferences of the patient and family/supports are in unison with the goals and clinical interventions of the rehabilitation team.
• Functions as a patient advocate and maintains patient confidentiality. Educate the patient, the family/supports, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions can be made.
• Promote patient self-advocacy, choice and self-determination. Educate patients and families/supports in the appropriate use of health care services. Improve quality of care and maintain cost effectiveness on a case-by-case basis.
• Provides discipline specific coverage within the Mary Free Bed System as requested.
• Participates in orientation and training of new staff.
• Supervises student internships as appropriate.
• Supports program operations as assigned.

• Leadership Must-Haves will be followed for patient and staff interactions:

Customer Service Responsibilities                                                                          

Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members. This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information.

Responsibilities in Quality Improvement                                                                 

Contribute by identifying problems and seeking solutions. Promote patient