Completes departmental orientation, initial and annual
Assists with departmental specific performance improvement
initiatives collecting and reporting data as requested by
As appropriate, consults other departmental staff to collaborate in
patient care delivery, identify barriers to care and or discharge
and develop solutions/resolution.
Completes documentation per workflow timeline and content
requirements including completion of the Individual Plan of Care
(IPoC) per CMS guidelines.
Schedules family conferences and/or communicates with caregiver
following each team conference and more often as needed to keep
patient and designated caregiver informed of progress and provides
appropriate information related to goal achievement, course of
rehabilitation stay, and plans for discharge.
Coordinates weekly patient care team conferences to facilitate
development, monitoring and refinement of treatment plan to achieve
identified patient goals and outcomes.
Reviews the patient's assigned CMG and helps the team identify any
potential missed comorbid conditions that are actively being
treated during the patient's stay. Communicates any findings to the
Communicates effectively with nursing, therapy and other ancillary
departments to ensure proper utilization.
If no Lead Case Manager, the CM participates as the facility
representative for national CM Conference calls and communicates
new information to the facility CMs.
Assists with concurrent and retrospective utilization review
activities including denials and appeals. Works with physicians to
conduct peer review with payer medical director when indicated.
Ensures clinical updates are provided to all insurance payers when
due and all payer communications are documented in Meditech.
Coordinates discharge planning needs including but not limited to;
home health services, physician follow up care, durable medical
equipment, medical supplies, healthcare services, outpatient
therapy, dialysis, skilled nursing care, assisted living care,
hospice care, private duty care, etc. Responsible for coordinating
all patient care needs prior to discharge ensuring a safe thorough
discharge plan. Ensures patient choice is offered and documented as
per CMS' Conditions of Participation for Discharge Planning.
Identifies trends that impact the quality, cost effectiveness,
patient experience and delivery of care services and brings to
departmental leadership meetings for discussion and action.
Performs intake assessment on patient within 24 to 72 hours of
admission, preferably within 48 hours.
Performs follow-up assessments per Case Management Plan and/or
Demonstrates an ability to be flexible, organized and function
under stressful situations.
Other duties as assigned.
Current Licensed ClinicalSocial Work licensure in state of RI
Masters of Social Work Degree
Certification in Case Management or Rehabilitation Nursing
preferred; for example, Commission for Case Manager Certification
(CCM); Association of Rehabilitation Nurses (ARN) certification,
American Case Management Association (ACM) or Board Certification
in CM by the ANCC e.g.: RN-BC
Minimum of 2 years social work or case management experience in an
inpatient setting highly preferred; acute/rehabilitation hospital
Effective oral and written communication skills in English,
additional languages preferred.
Basic computer skills in excel, word, outlook, power point, etc.
Must have good organizational skills, time management skills and
analytical ability in order to interpret information and carry out
Must be cooperative and have the desire to be a team player.
Must recognize and observe confidentiality principles.