• Performs intake assessment on patient within 24 to 72 hours of admission.

• Performs follow-up assessments per Case Management Plan and/or hospital policy.

• Utilizes patient care in collaboration with all members of the healthcare team. Active participant in patient and family conferences.

• Keeps patient and designated family member/responsible person informed of progress and provides appropriate information related to goal achievement, course of rehabilitation stay, and plans for discharge. Functions as a patient/family advocate.

• Assists with the utilization management function.

• Orders and arranges for home care equipment, follow up care and healthcare needs following rehabilitation stay.

• Works with third party payers to validate need for patient care and home care environment needs.

• Educates patient and family on all aspects of patient's hospitalization and continuing care.

• Reviews patient care activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services. Assures that the outcome of review is appropriately maintained in the computer database.

• Assumes responsibility for timely completion of required case management reports for regulatory bodies, health plans, insurance carriers and the leadership team.

• Demonstrates an ability to be flexible, organized and function under stressful situations.

• Consults other departments, as appropriate, to collaborate in patient care and performance improvement activities. Collaborates with other departments to identify operational problems and develop solutions/resolution.

• Follows state and federal requirements regarding discharge planning.

• Documentation meets current standards and policies.

• Responsible for discharge planning; assures patient returned from hospital to safe environment.

• Maintains optimal continuum of patient care through efficient and effective planning, assessing and coordination of healthcare services.

• Other duties as assigned.

MON-HR
LI-HR