Job Description

The Case Manager is responsible for coordinating all facets of the guests stay and discharge plan in the Rehabilitation and Wellness Pavilion. The coordinator will ensure that guests are acclimated to and satisfied with Pavilion services by working across departmental lines to ensure seamless delivery and coordination of services for the duration of the Guest stay.

PRIMARY RESPONSIBILITIES

1. Complete 48-hour Care Plan – Meet with guest and family member; provide introductions; staff contact information, medication list, and Davis Guest Services Binder. Discuss insurance Medicare 20 days, Navi health, Humana, BCBS, BCBS Federal, Aetna etc. and update emergency telephone numbers if necessary, and discuss discharge plan/goal. Call first emergency contact (unless guest says otherwise) if not in the room and explain the same and document.

2. Collaborate with interdisciplinary team to facilitate discharge planning and recommendations considering all aspects of the discharge process. Coordinate with IDT to ensure constant communication exchange of information at team meetings.

3. Develop collaborative relationships with other departments, entities and external health care agencies to facilitate and support quality of care and discharge planning.

4. Contact outside resources for continuum care such as Home Health Agencies as well as DME companies to ensure a safe discharge to include wellness opportunities at The Davis Community.

5. Act as an educational resource for guests, families, and interdisciplinary team members.

6. Schedule and facilitate family meetings for potential discharge as well as updates of resident progress.

7. Direct daily operations of record processing to ensure that discharge records are properly received, organized and forwarded to the appropriate physician for completion.

8. Daily communication guest/family contact, maintaining communication with physicians, guest care providers, and other team members regarding treatment plans in order to ascertain appropriate level of care, coordinate timely delivery of services, assist staff in identifying and addressing the learning needs of guest and families and intervene as appropriate.

9. Obtain information from medical record, interdisciplinary team, family members and the clients to assess client's capabilities, needs and interests.

10. Complete scheduled MDS assessments in a timely and accurate manner and develop care plan to meet needs of guest, based on needs assessment and client interest. Implement and follow through on care plan approaches. Document guest interactions, progress, and discharge plans in the guest medical record.

11. Collaborate with MDS nurse to update on any changes/discharge’s/20 days/100 days/no secondary/federal BCBS/Humana/UHC/5day MDS etc.

12. Collaborate with therapy weekly in regard to updates/family meetings/discharges and email the updates from this meeting to physicians and NPAs.

13. Complete Life Source referrals as needed and fax to Life Source with a Physician/NP order/face sheet and wait for approval.

14. Perform 1:1 interaction and in- room visits to meet rehab needs and document outcome. Document any conversations/interactions with guests/family members.

19. Work collaboratively with the Social Worker for coverage ensuring consistent communication and systems are utilized.

20. Communicates facility philosophy, offered services and amenities to potential and new residents and/or their representatives.

21. Acts as liaison between transferring institutions and the Center by maintaining a good rapport.

22. Conducts tours for prospective residents.

Requirements

Education: High School Diploma required. Bachelor’s Degree or Associates Degree preferred.

Licensure/ Certification: None.

Experience: Two years of related health care/case management/discharge planning/social work or recreation experience.

An equivalent combination of education and experience may be considered.