Job Description

The Case Manager is responsible for coordinating and facilitating high-quality, patient-centered care across the continuum of services. Through early identification and assessment of patient needs, the Case Manager collaborates with patients, families, providers, and interdisciplinary team members to develop and implement effective care plans. As a key member of the healthcare team, the Case Manager promotes timely access to services, supports care transitions, addresses barriers to care, and helps optimize patient outcomes while ensuring efficient utilization of healthcare resources.

The Case Manager plays an integral role in discharge planning by proactively identifying patient needs, coordinating post-acute services, and facilitating safe and timely transitions of care. Through collaboration with the interdisciplinary team, the Case Manager works to improve patient outcomes, reduce readmission risk, minimize avoidable days, and ensure patients receive the appropriate level of care throughout their healthcare journey.

Patient Assessment, Care Planning & Care Coordination-45%

• Conduct comprehensive assessments to identify patient, family, and caregiver needs, including medical, psychosocial, financial, and environmental factors.
• Develop, implement, and monitor individualized care plans in collaboration with patients, families, providers, and interdisciplinary team members.
• Coordinate care and services across the continuum, including inpatient, outpatient, community-based, and specialty care settings.
• Facilitate timely referrals to internal and external resources, programs, and community agencies.
• Support care transitions and discharge planning to ensure continuity of care and reduce barriers to treatment.
• Monitor patient progress toward established goals and modify care plans as needed.
• Advocate for patients and families to promote access to appropriate healthcare services and resources.

Patient, Family & Community Engagement-25%

• Educate patients and families regarding diagnoses, treatment plans, available resources, and self-management strategies.
• Collaborate with physicians, nurses, social workers, therapists, and other healthcare professionals to optimize patient outcomes.
• Identify and address barriers to care, including social determinants of health that may impact treatment adherence and health outcomes.
• Serve as a resource and liaison for patients, families, providers, and community partners regarding care coordination services.
• Promote patient and family engagement in care planning and goal setting.
• Foster partnerships with community organizations and service providers to improve access to care and support.

Documentation, Quality & Population Health Management-25%

• Maintain accurate, timely, and complete documentation in accordance with organizational, regulatory, and payer requirements.
• Participate in quality improvement initiatives, care management programs, and performance metrics related to patient outcomes and resource utilization.
• Ensure compliance with organizational policies, accreditation standards, and applicable federal and state regulations.
• Utilize data and population health tools to identify high-risk patients and support proactive care management interventions.
• Monitor care coordination outcomes and contribute to organizational performance improvement efforts.

Administrative & Other Duties-5%

• Monitor care coordination outcomes and contribute to organizational performance improvement efforts.
• Attend departmental meetings, training sessions, and professional development activities.
• Participate in organizational initiatives and special projects as assigned.
• Performs other job-related duties as assigned.

Education and/or Experience Required:

• Education: BSN Required.
• Experience: At least 3 yrs. experience in a healthcare setting required.

Education and/or Experience Preferred:

• Experience: Pediatrics, Case Management, Discharge Planning preferred.

License and/or Certification Required:

• Current State of Connecticut Registered Nurse licensure.

License and/or Certification Preferred:

• Case Management Certification.

Knowledge, Skills and Abilities:

Knowledge:

• Demonstrates working knowledge of clinical care management principles, utilization management practices, and the interpretation and application of medical necessity and level-of-care criteria.
• Knowledge of healthcare delivery systems, discharge planning processes, care transitions, and interdisciplinary care coordination.
• Understanding of community resources, treatment options, home health services, durable medical equipment, behavioral health resources, and post-acute care services.
• Knowledge of funding sources, insurance benefits, payer requirements, governmental assistance programs, and other financial resources available to support patient care needs.
• Familiarity with special programs and community-based services that address medical, developmental, behavioral, educational, and social determinants of health.
• Knowledge of applicable federal, state, regulatory, and accreditation standards related to case management and patient care.
• Understanding of patient and family-centered care principles and strategies for engaging patients and caregivers in care planning and decision-making.
• Proficiency in electronic medical records, documentation standards, and healthcare information systems used to support care coordination and case management activities

Skills:

• Coordinates the management of care for a designated patient population, ensuring continuity of care across the healthcare continuum and promoting optimal utilization of resources, quality service delivery, and compliance with organizational standards.
• Conducts comprehensive assessments to identify patient and family needs and develops individualized care plans that support safe, effective, and timely transitions of care.
• Provides ongoing care management support through assessment, planning, implementation, monitoring, and evaluation of patient-centered interventions and outcomes.
• Collaborates effectively with patients, families, healthcare providers, and community partners to facilitate care coordination and resolve barriers to care.
• Demonstrates strong critical thinking, clinical judgment, problem-solving, and decision-making skills in a fast-paced healthcare environment.
• Utilizes effective verbal and written communication skills to educate patients and families, advocate for patient needs, and support interdisciplinary collaboration.
• Manages multiple priorities while maintaining attention to detail, organization, and timely follow-through on patient care needs.
• Demonstrates proficiency in the use of healthcare technology and electronic medical records, including navigation and documentation within EPIC.
• Skilled in computer applications, including Microsoft Word, Excel, Outlook, and other software programs necessary for care coordination, reporting, and data management.
• Applies knowledge of community resources, insurance requirements, and available services to connect patients and families with appropriate supports and resources.

Abilities:

• Work independently while demonstrating initiative, sound judgment, professionalism, and a collaborative, team-oriented approach.
• Function effectively in a high-energy, fast-paced healthcare environment while maintaining quality, accuracy, and attention to detail.
• Adapt to changing patient needs, priorities, and unit acuity with flexibility and responsiveness.
• Prioritize and manage a complex caseload while meeting deadlines and maintaining continuity of care.
• Coordinate and collaborate effectively with interdisciplinary teams, healthcare providers, patients, families, and community partners.
• Communicate clearly, professionally, and compassionately with diverse populations across multiple settings.
• Analyze information, identify barriers to care, and develop practical solutions to support patient and family needs.
• Manage multiple responsibilities simultaneously while maintaining organization and efficiency.
• Exercise critical thinking and problem-solving skills in complex clinical and care coordination situations.
• Maintain confidentiality and handle sensitive information in accordance with organizational policies and regulatory requirements.
• Demonstrate excellent written and verbal communication skills, including documentation, patient education, and professional correspondence.
• Build and maintain effective working relationships with internal and external stakeholders to support coordinated, patient-centered care.