Providing social services to all hospitalizations including swing bed patients.

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

The Care Management is expected to perform the following essential functions:

• Coordinates/facilitates patient progression throughout the continuum and effectively communicates with patient and family
• Effectively conducts and documents pre-admission screening referrals regarding patients in the Swing bed program.
• Addresses/resolves system problems impeding diagnostic or treatment progress; proactively identifies and resolves delays and obstacles to discharge
• Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge
• Perform Utilization Management, and Quality Screening for assigned patients
• Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards
• Utilizes InterQual criteria to ensure appropriate level of care
• Communicates utilization findings and patient specific case management issues to care management team
• Identifies at-risk populations using approved screening tool and follows established reporting procedures
• Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas
• Communicates with business department about reimbursement for assigned patients and discusses payor criteria and manages all aspects of discharge planning for assigned patients; queries and schedules discharge planning meetings with swing bed patients and their representatives
• Meets directly with patient/family to assess needs and develop an individualized discharge plan in collaboration with the hospitalist.
• Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation

• Documents relevant discharge planning information in the medical record according to Department standards
• Actively participates in clinical performance improvement activities
• Uses data and reports hospital and quality measure criteria
• Collects delay and other data for specific performance and/or outcome indicators as determined for Critical Access Status
• Participates in development, implementation, evaluation and compliance of swing bed criteria for hospital
• Facilitates and promotes swing bed admissions both internally and externally. Coordinates skilled admissions with social workers from referring facilities
• Daily rounding regarding patient’s home situation, medical equipment needs, caregiver and PCP status
• Discharge management includes obtaining Home Health referrals, DME placement, etc.
• Coordinates Nursing Home Placement
• Facilitates chart review for Critical Access Compliance and Morbidity and Mortality Review
• Exceptional interpersonal skills with excellent written and verbal skills
• Complete a psychosocial discharge form for each admission
• Completes initial, weekly and monthly multidisciplinary updates for charting.
• Attend daily care management meeting for discharge planning
• Ongoing reviews of certification status.
• Serves on Grievance Committee at direction of CNO.
• And any other job duties assigned.

• Enter all required competencies.

• None

• Ability to perform various motor skills such as; standing for long periods of time, walking, lifting (up to 50 pounds) using proper lifting techniques, stair climbing, reaching, bending, twisting, pushing, pulling, squatting, grasping and arm-hand coordination on a continuous basis.

• None

• Must be have a Bachelor’s Degree in Social Work. Master degree is preferred.
• Minimum of 1 year experience in Care Management in a healthcare environment.
• Must comply with and promote HIPAA regulations.
• Must demonstrate computer skills.

• Must be familiar with regulatory standards for Critical Access Hospital

• Describe preferred education and experience for the position that are job-related and consistent with business necessity.

Please note this job description is not designed to cover or contain a comprehensive listing of all activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time.

Boone Memorial Hospital, Inc. provides equal employment opportunities to all personnel and applicants for employment and prohibits discrimination, harassment, prejudice, or behavior of any type based on race, color, religion, age, sex (including pregnancy), national origin, disability status, family medical history or genetic information, past or present military service, sexual orientation, gender identity or expression, family or parental status, political affiliation, or any other characteristic protected by federal, state or local laws.