(RN) Lead, SNF Case Manager

Position Summary:

Under the direction of Director, Social Services and collaborating closely with Case Management Teams, the Advance Care Planning (ACP) Case Manager is responsible for assisting in the successful implementation of Advance Care Planning (ACP) Management Program in the North Region. This program is designed to establish early identification and focused care coordination of eligible/potentially eligible members requiring end of life planning and facilitate appropriate services for the member.

The primary goal of the Advance Care Planning (ACP) CM is to effectively identify hospice/palliative appropriate members on an inpatient/outpatient basis to assure that these members are transitioned to palliative/hospice care by working in partnership with our contracted hospice companies wherever possible. To this end, the Advance Care Planning CM will offer professional facilitation to our eligible and potentially eligible members to assist them in developing and articulating their wishes regarding their end of life issues, including palliative/hospice care.

Further, the Advance Care Planning CM will Provide assistance to members and their families in the form of end of life planning guidance and resource referrals.

Essential Duties And Responsibilities include the following:

• Identifies hospice appropriate members through Advance Care Planning consultations and work to enroll those members onto hospice/palliative care as appropriate.
• Receives referrals from: TCM members for possible hospice/palliative care needs, Outpatient CM's, PCP's/CQC Meetings or administrators from medical group operations, Social Workers and Medical Directors/Administrators/Clinical Project Managers.
• Review the daily Inpatient and discharge reports to determine appropriate candidates for hospice/palliative care.
• Collaborates with Clinical Liaison from Valley’s Best to identify eligible palliative/hospice Members from Disease and Life Planning Registry.
• Attends and Participates in ICT meetings, PCP/CQC meetings, or administrative conferences, inpatient rounds and social worker referrals that involve potential hospice/palliative care referrals, as requested/needed.
• Interacts professionally with member/family/physicians and involves member/family/physicians pertaining to ACP activities.
• Consults with social workers/case managers to facilitate in-services, and works with VBH to coordinate frequent staff in services, onboarding SW/CMs and provided training with staff model clinics.
• Visits with clinics to build relationships with providers.
• Conducts ACP consults/visits with patients in the hospital, community, home, provider clinic to facilitate palliative/hospice transition.
• Visits patients in the hospital, community, home, provider clinic to facilitate palliative/hospice transition.
• Visits hospitals for end of life discussions/hospice transitions if in agreement with hospitalist and RMD and if needs are not psychosocial (otherwise SW to attend and joint visit with SW performed)
• Completes telephonic consultations with member/family about end of life planning as necessary.
• Reviews all North hospice discharges in real time (revocations/discharges for extended prognosis) for possible re-conversions to hospice/palliative care (Not to take over case management for post hospice discharge needs).
• Reviews hospice authorizations (clinical) to determine if member is hospice/continues to be hospice appropriate and provider has the appropriate LOC based on medical record submission.
• Conducts clinical discussions with hospice provider as needed to ensure members continue to be appropriate and are receiving the appropriate LOC.
• Collaborates with assigned Case Manager/Physician for members that are not palliative/hospice appropriate or do not convert to Palliative/Hospice Care; or be able to outsource to Social worker or other resources as appropriate to meet member’s specific needs.
• Works on special project proposals to increase hospice/palliative referrals and enrollments.
• Provides education on hospice, advance healthcare directives, and POLST.
• Assists in educational endeavors of department.
• Assists with chart auditing and maintain quality monitors as assigned by Manager
• Participates in orientation, instruction/training of new personnel.
• Pursues additional education (in-services, seminars, self-study, and formal education programs) to advance skills and knowledge.
• Documents appropriately pertinent information completely, in the electronic medical documentation system.
• Prepares reports and compiles statistical data regarding members, as determined by the management team.
• Protects privacy for both members and