| Responsible for the initial review, triage and assignment of patients to case managers and for the coordination of all systems and services required for an organized, multidisciplinary, patient centered care team approach. Assure quality, cost effective care for the identified patient population. Supervise staff in the department. Acts as a resource and role model for staff. The incumbent also functions as a contact person for the patient, family, health care team members, community resources and employees. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include Neonate, Pediatric, Adolescent, Adult and Geriatric age groups. |
PCMH/PCSP - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable
IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral
SUPERVISION - Develop efficient organizational structure, supervise employees - select, terminate, train, educate, correct deficiencies, perform appraisals, issue discipline, counsel, schedule work assignments; encourage staff teamwork and growth initiatives
DATA - Perform assessment, data collection, obtain, review, and analyze information in collaboration with the patient, family, significant others, health care team members, employers, and others as appropriate
ASSESSMENT - Assess the patient's clinical, psychosocial status and current treatment plans
NEEDS - Assess the patient/family/significant others needs in relation to the medical diagnosis and treatment and resources; provide treatment options, financial resources, psychosocial needs, and discharge planning in collaboration with appropriate resources
COLLABORATION - Develop collaborative relationships with other departments/services and community health care agencies facilitating and supporting quality care in area of clinical expertise; act as a resource on complex patient care activities
ASSIGNMENTS - Oversee and assign case loads and staff hours to best suit Hospitals needs
COVERAGE - Organize case coverage during absence of staff
PERFORMANCE - Assist in developing standards of performance, evaluation of performance, and initiates or makes recommendations for personnel actions
LEADERSHIP - Provide leadership through identification of problems and opportunities for improvement, program planning, implementation, and evaluation
GOALS - Assist the patient, family, significant others to set patient-centered goals for individual patient, family, and significant others in collaboration with physicians, staff RNs and other health care team members
PLAN OF CARE - Develop comprehensive multidisciplinary plan of care effectively utilizing tools and resources
DISCHARGE PLANNING - Conduct timely discharge planning by anticipating patient needs in collaboration with physicians, staff RN's, and other health care team members
VARIANCES - Intervene when variances occur in patient individualized treatment plan
RESOURCES - Coordinate and evaluate the use of resources and services in a quality-conscious, cost effective manner and collaborate with appropriate providers to ensure effective, quality outcomes
INTERVENTIONS - Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessary
VARIANCE - Review variance from standardized protocols of care with health care team members and implement resolution strategies
TREATMENT CONFERENCES - Facilitate and/or participate in conferences providing ongoing evaluation of interdisciplinary dynamics, goals attainment and treatment management
EDUCATION - Ensure and/or provide instruction to the patient and family based on identified learning needs; assess patient/family knowledge, health status expectations, and locus of control
INFORMATION - Assist with development of activities and methods to ensure information is articulated and disseminated to appropriate members of the health care team
CONTINUITY OF CARE - Collaborate with the health care team to ensure continuity of patient care throughout all health care settings; promote effective communication among health care team members including the patient, family, and significant others
MEETINGS - Participate in team meetings when indicated or as directed
CARE PLAN - Incorporate recommendations and/or services of interdisciplinary team members in the care plan
COMMUNICATION - Use interpersonal communication strategies with individuals as well as groups of patients, families, significant others, and staff to achieve expected outcomes and patient/family and health care team satisfaction
DOCUMENTATION - Provide routine verbal and written documentation for the initial assessment and progress of the patient to other members of the health care team in a timely manner
ORIENTATION - Participate in orientation, continuing education of staff RN's and other health care team members as appropriate
RELATED WORK - Perform related duties and responsibilities as required
PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"
ADMINISTRATION - Perform various administrative functions such as monitoring expenditures and preparing reports and correspondence; may participate in a variety of research projects to develop service plans; may propose changes to program policies and procedures
DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
STAFF - Assist in interviewing, hiring, orienting, training, coaching, evaluating, counseling, and supervising staff
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