JOB TITLE:Case Manager, TIP & ED Prevention Programs
REPORTS TO: Director of Advanced Practice Clinicians
JOB OVERVIEW: Responsible for identifying and recruiting hospital patients for the Transitional Improvement Program (TIP) as well as coordinating care in collaboration with an Advanced Practice Provider. Additional duties will include ED prevention objectives to reduce hospital readmissions.
ESSENTIAL FUNCTIONS OF THE JOB INCLUDE, BUT ARE NOT LIMITED TO:
Review MedOne daily patient lists to identify potential Medicare discharges
Visit identified patients in the hospital and explain the Transitional Improvement Program with the goal of enrollment. This will require education and discussion with family members to explain the benefits of enrollment.
Contact enrolled patients by phone within two days after discharge
Document, communicate and collect patient data to evaluate and improve timeliness and appropriateness of care with the goal of avoiding hospital re-admission.
Provide ongoing support and expertise through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs
Act as a liaison between physicians, outside offices, nurses, pharmacy, laboratories, home health companies and other support services needed by the patient to organize and coordinate cost effective and patient-centered care to maximize outcomes and avoid hospital readmission
May assist in the scheduling of diagnostic tests and treatment modalities, prescription drug instructions and other services
Provides patient and family health education and health assessment during the treatment period
Education:Associate or bachelor’s degree in Nursing
Current Ohio Registered Nurse license
Experience: 3 Years prior Case Management experience required
Highly organized; Ability to multi-task and prioritize
Clinical knowledge to facilitate patient care under the direction of a physician or advanced practice provider
Excellent communication skills at the patient and physician level
Detail oriented; Able to follow note standards for documentation
Ability to work independently and collaborate with team members including providers and outside resources as needed
Ability to establish and maintain effective working relationships with providers, staff and contacts outside the organization; Engage in MedOne culture
Able to maintain strict patient confidentiality and follow HIPAA rules and regulations
Internal Number: 01
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