Case Manager

Job Description

This position is responsible for assessing, developing, implementing, and monitoring a comprehensive plan of care through an interdisciplinary team process in conjunction with patients and families in diverse settings. The role involves comprehensive assessment of patients’ goals as well as their biophysical, psychosocial, environmental, functional, and financial status. The Case Manager also procures services and advocates on behalf of patients and families for scarce resources, directing families to arrange for necessary services. Additionally, the Case Manager acts as a liaison to post-hospital care providers and community health resources.

Essential Job Functions

• Assessing patients’ healthcare needs and developing comprehensive care plans.
• Facilitating communication between patients, families, and healthcare providers.
• Coordinating transitions between various care settings.
• Ensuring continuity of care throughout the treatment process.
• Evaluating medical necessity for treatments, procedures, and hospital stays.
• Collaborating with insurance companies to obtain authorizations.
• Monitoring length of stay and identifying potential discharge barriers.
• Ensuring appropriate use of healthcare resources.
• Advocating for patients’ needs and preferences with the healthcare team.
• Educating patients and families about diagnoses, treatments, and self-care.
• Connecting patients with community resources and support services.
• Addressing barriers to care, including financial, social, and logistical challenges.
• Regularly reviewing and updating care plans based on client progress.
• Facilitating referrals to specialized services as needed.
• Maintaining accurate and thorough case management records.
• Documenting assessments, interventions, and outcomes.
• Tracking quality metrics and patient outcomes.
• Preparing reports for healthcare teams and administration.
• Participating in interdisciplinary care conferences.
• Coordinating care plan implementation across disciplines.
• Supporting the organization’s mission, vision, values, policies, and procedures.
• Participating in required education and training programs.

Personal Traits, Qualities, and Aptitudes

• Positive interpersonal skills, both on the phone and in person.
• Ability to convey empathy and compassion in conversations.
• Capable of fostering teamwork, cooperation, and confidence among colleagues.
• Independently works and completes assignments in a timely manner.
• Recognition of and adherence to patient confidentiality rights.
• Effective communication skills with diverse socio-economic backgrounds.
• Ability to relate well to patients of all ages, including children, adolescents, adults, and geriatrics.

Qualifications

• Education:
  • Required: Graduate of an accredited school of medicine, social work, nursing, or a related medical occupation.
  • Preferred: Previous experience with coordinating community resources for post-acute hospitalization care. BSN/MSN.
• Licenses/Certifications/Registrations:
  • Required: Active Oregon RN License, CRASE training.
  • Preferred: Case Management Certification.
• Experience:
  • Required: Previous clinical experience in an acute care setting or home health setting, assessing skilled care needs and health maintenance resource needs.
  • Preferred: Previous Discharge Planning and/or Case Management experience.
• Other: Bilingual and/or English-Spanish speaking preferred, with the ability to work with a culturally diverse population.

Physical Requirements

The position requires sufficient auditory ability to detect and respond to various sounds, including patient alarms and verbal communication. Clear and effective communication is essential, along with the ability to interact with patients, families, and healthcare team members. Visual acuity is necessary for observing patient conditions, reading documentation, and monitoring equipment. The role may involve occasional lifting of individuals weighing over 100 pounds, requiring proper lifting techniques. The position may also involve sitting for extended