HSCPC Case Manager

The Medical Case Manager oversees HSC patients’ progression through the continuum of care through individualized care coordination and discharge planning. The Medical Case Manager facilitates transition to the appropriate discharge disposition through effective communication with the Interdisciplinary Team (IDT), community hospital case managers, social workers, community physicians and payer case managers, etc.

Minimum Education
BSN (Preferred)
 

Required Experience:

Must have three (3) to five (5) years of clinical experience in NICU, PICU or Pediatric Nursing. Demonstrated knowledge and skills necessary to provide age appropriate care to the patients served by the hospital; including knowledge of growth and development principles over the life span. Highly developed communication and organizational skills. Ability to communicate effectively with internal and external individuals and groups of all levels. Able to manage multiple priorities. Bilingual in Spanish highly preferred.

Required Skills/Knowledge
Demonstrated expertise in analysis and decision- making.
Good clinical assessment skills, including knowledge of rehabilitation potential.
Ability to function independently with superior time management skills.
Outstanding oral and written communication skills.
Well-developed computer skills.
Must maintain a good driving record and be able to safely operate a motor vehicle and/or van.
Must be able to perform a hands-on assessment of a child.
Ability to manage multiple priorities and make appropriate decisions to ensure completion of tasks.

Required Licenses and Certifications
Registered Nurse in District of Columbia Licensure as a registered nurse in DC, MD, or VA. (Required)
Current driver’s license. (Required) Certification in rehabilitation nursing or a related specialty. (Preferred)

Job Functions

Essential job duties:

1. Identification of preliminary discharge needs at time of Case Manager Admission Assessment. At that time, instructs patient, family/caregivers at that time about the discharge planning process; and, the importance of their participation in that process.
2. Acts as a liaison between HSC staff, patients, caregivers and community discharge resources.
3. Develops and maintains ongoing relationships and communication with Clinical and Medical staff; as well as community resources (external hospital staffs, home care agencies, outpatient therapy providers, DME companies, pharmacies, transportation companies, etc.) regarding patients requiring post hospitalization services through discharge.
4. Makes appropriate referrals to community agencies in preparation for discharge; and coordinates communication between family/caregivers and the agencies. Follows up on concerns identified by community agencies about the appropriateness of the discharge plan.
5. Ensures discharge medications and durable medical equipment are ordered in a timely manner.
6. Ensures patient, family or caregiver has identified a Primary Care Provider (PCP) and scheduled a post-discharge follow up appointment. Schedules PCP appointment, if patient or caregiver has difficulty doing so. Schedules follow up appointments.
7. Ongoing communication with nursing staff re: education provided and portions requiring Nursing reinforcement.
8. Reports teaching progress at weekly IDT Rounds, including readiness for discharge.
9. Coordinates Family Meetings with Unit Social Worker to assess patient and family/caregiver readiness for discharge.
10. Coordinates Family Apartment Stays with Unit Social Worker to assess patient and family/caregiver readiness for discharge.
11. Arranges discharge transportation, as needed.
12. Addresses last minute patient, family/caregiver questions/concerns at the time of discharge; including additional discharge teaching on medications and follow up appointments.
13. Completes the Case Management-Social Work Discharge Summary with the Social Worker. Provides copies to patient, family and/or caregiver, PCP and appropriate healthcare providers, as needed

Other job duties:

1. Schedule Clinic Appointments for in house patients.
2. As needed coverage for the Admissions Case Manager and UM/UR Nurse.
3. May perform other duties in addition to those outlined in this job description.

Organizational Accountabilities
Organizational Accountabilities (Staff)
Employee Excellence

• Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence standard is achieved

• Innovates through improvement of care and/or efficiency of operational processes.

• Dedicated to a standard of performance excellence and high quality

All In

• Embraces changes/improvements and actively participates in the implementation of new/improved programs, technology, new equipment, systems and resources that promote quality of care, safety and efficiency

• Identifies, prioritizes and selects alternative solutions to determine best outcome

Action Oriented

• Maintains a high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands

• Anticipates problems and attempts to solve before they develop

Supervisory Responsibilities

• None

Blood Borne Pathogen Exposure

• Category II: Job may expose incumbent occasionally or in emergency situations to blood, body fluids, non-intact skin or tissue specimens.

Protected Health Information Access Level

• Level IV - Full Access Incumbents in this job may access any protected health information associated to a customer's needs, the service(s) rendered and the position's functions.

Working Environment

• This job operates in a hospital environment.

Physical Requirements

• Light Work: Lifting 25 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs.

Travel Requirements

• Occasional travel around the Washington, DC area is required.