The Case Manager is responsible for ensuring patient progress and meeting and facilitating a safe and sustainable transition plan. Collaborates with Physician and Interdisciplinary Team to determine plan of care, treatment, estimated LOS, and likely discharge disposition (home, LTAC, SNF, or ALF). Ensures that Physician/Interdisciplinary Team discusses estimated LOS, tentative discharge date, and assessed needs for discharge with the patient and family. Reviews medical record to anticipate clinical stability and to have a thorough understanding of the patient prior to speaking with the physician and/or participating in multidisciplinary rounds/huddles. Participates in interdisciplinary Rounds or Huddles. Ensures patient is progressing through clinical milestones and adjusting the targeted discharge day as indicated. Collaborates with Interdisciplinary team members to continuously identify more effective strategies to resolve barriers, improve processes and systems, and change practice as indicated.
Escalates barriers to the plan of care (clinical, social, and environmental) through appropriate channels to resolution. Works in partnership with physicians to consider alternate levels of care if patient is not meeting acute care criteria. Facilitates communication among physicians caring for patient to advance plan of care. Monitors and documents avoidable days and documents anticipated discharge date in medical record for all patients. Plans medical discharge needs. Collaborates with Social Work to manage the needs of patients who have high acuity psychosocial needs coupled with need for medical post- acute care to ensure successful reintegration into the community and to mitigate risk for readmission. Supports the efforts of HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems/data bases. Responsible for performing job duties in accordance with the mission, vision and values of Tampa General Hospital. In addition to the above duties, the Emergency Department (ED) Care Coordinator (CC) provides hand-off communication to acute care staff, directs patient assignments to appropriate admitting/Hospitalist service, leads consultation regarding appropriate bed placement, and identifies and diverts unnecessary admissions from ED to community-based providers. ED CCs identify recidivistic patients and work with Social Work and community-based providers to decrease ED over-utilization. Creates, implements, and updates Patient Specific Action Plan (PSAP) on ED frequent utilizers, communicating PSAP to all members of the Interdisciplinary Team with each admission to the hospital. Identifies and ensures documentation of conditions that may be “present on admission.”
Technical Skills and Responsibilities:
Accountable for developing and coordinating the implementation of Discharge Plan A and alternative Plan B, including documentation in the medical record.
Holds, interprets, and integrates the patient's story into the overall multidisciplinary plan of care
Coordinates/facilitates access to services and patient care progression using best practice interventions that will produce favorable patient outcomes within a target LOS
Collaborates with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient delivery of care in the appropriate setting
Uses the Physician Advisor per protocol for complex issues related to physician practices or behaviors. Determines next steps for the patient and physician with the Physician Advisor.
Leads or co-leads Care Coordination Rounds per policy and refers patients for Complex Care Rounds
Actively participates in clinical performance improvement activities as assigned
Builds a network of positive working relationships that advocate for the patient
Conduct team meetings for all unplanned readmissions that occur within 30 days
Complete whatever paperwork is necessary to facilitate the patient's transition through levels of care.
Tampa General is a private not-for-profit hospital and one of the most comprehensive medical facilities in West Central Florida serving a dozen counties with a population in excess of 4 million. As one of the largest hospitals in Florida, Tampa General is licensed for 982 beds, and with over 15,000 team members, is one of the region’s largest employers.
Consistently recognized for world-class care, Tampa General Hospital is ranked as the #1 hospital in Tampa Bay by U.S. News & World Report for 2024-25 and is nationally ranked as among the top 50 hospitals in the nation in eight specialties. Additionally, Tampa General was ranked as “high performing,” or among the top 10% of hospitals in the nation, in five more specialties along with 12 procedures and conditions.
TGH partners with the USF Health Morsani College of Medicine to pioneer breakthrough treatments, conduct game-changing clinical research and train the next generation of health care professionals. TGH is the region's only academic health system, having been affiliated with the USF Health Morsani College of Medicine since the school was created in the early 1970s.
TGH is the area’s only Level I trauma center and one of two ABA-verified Adult & Pediatric burn centers in Florida. With five medical helicopters, we are able to transport critically injured or ill patients from 23 surrounding counties to receive the advanced care they need. The hospital is home to the leading organ transplant center in the country, having performed more than 14,000 adult solid organ transplants, including the state’s first successful heart transplant in 1985. Tampa General Hospital is committed to serving all residents of West Central Florida. We provide comprehensive health services, ranging from wellness and primary care to the most complex specialty care and post-acute services.
