Social WorkerCase Manager Frazier Rehab

The Case Manager provides comprehensive assessments of the patient (adult and/or pediatric) family and support system serving as the primary liaison between the patient / family and the treatment team. The Case Manager ensures that the patients individualized treatment plan is carried out in a focused cost effective goal directed manner. As a member of the interdisciplinary team the case manager will also facilitate the development coordination and implementation of the discharge plan as well as any other outside arrangements to ensure continuity of care. The case manager also serves as the primary liaison facilitating communication with insurance companies referral sources and community resources as appropriate. It is the Case Managers responsibility to ensure that patients in any phase of the program (acute outpatient community reentry) proceed through rehabilitation according to established program guidelines and protocols.

1. Assists in delivering high quality health care services in a professional compassionate and courteous manner while respecting the dignity and individuality of each person who comes in contact with the organization by following the Standards of Excellence the Standards of Behavior and the Standards of Professional Appearance and Conduct. (Mandatory for all employees)
1.1 Maintains patient privacy and confidentiality at all times according to established procedures.
1.2 Follows the Standards of Professional Appearance and Conduct and the departmental dress code.
1.3 Communicates effectively and courteously answering assigned telephone lines within three rings identifying self at all times.
1.4 Assists visitors and patients in giving directions and information.
1.5 Communicates effectively and courteously with all visitors physicians patients and employees.
1.6 Introduces self and position to patients families and visitors at all times.
1.7 Assesses environment for safety hazards which could harm patients visitors or other hospital employees and reports hazards to appropriate supervisors.
1.8 Collaborates with other departments and outside agencies to meet the identified needs of the patients and the organization.

2. Knowledge and performance of Code of Conduct Standards is evident in performing daily activities. (Mandatory for all employees)

3. Work reflects the employee honors the Frazier Rehab Institute Mission Statement Vision Statement and Corporate Values. (Mandatory for all employees)

4. Demonstrates the knowledge and skills necessary to interact with and provide care appropriate to the age of the patients served. (Mandatory on all patient care positions)
4.1 Demonstrates sensitivity to the age of the patient and/or family in all communication interactions.
4.2 Demonstrates proficiency in the operation of equipment utilized to perform the essential function of the job.4.3 Demonstrates knowledge related to age appropriate behavior of adolescents adults and
geriatrics to assess the psychosocial needs of the patient.

5. Provide initial assessment upon a patients planned admission to any access point of the continuum of care reflecting the patient/familys current and anticipated healthcare social educational financial and vocational needs and resources.
5.1 Conducts initial assessment within 48 hours of a patients admission to the Hospital as evidenced by documentation.
5.2 Demonstrates working knowledge and understanding of the injury illness disability and diagnosis as well as corresponding medical developmental and /or educational needs both current and projected of the patient as evidenced by documentation.
5.3 Interprets and integrates data from interview with the patient and/or family medical records and the rehab team in order to provide an accurate assessment of the patients current status and needs as evidenced by documentation.
5.4 Generates with the treatment team a set of recommendations that identify projected healthcare needs and/or educational recommendations that are congruent with the developmental stage of the patient as evidenced by documentation.
5.5 Relates initial recommendations and proposed treatment plan to the patient and/or family as documented in the patient record.
5.6 Provides the initial discharge planning recommendations to the treatment team prior to or during the first team rounds.
5.7 Facilitates communication of initial assessment and treatment plan to third party payor contact within 24 hours of the first team rounds or as otherwise indicated by specific instructions.

6. Coordinates the overall discharge plan for the patient and family.
6.1 Develops an integrated comprehensive discharge plan in consultation with the patient family and team as documented in the patient record.
6.2 Revises the discharge plan according to assessed changes in patient/family needs and rehab team recommendations as documented in the patient record.
6.3 Coordinates the implementation of the overall discharge plan by the rehab team as reflected in documentation and observation by supervisor.
6.4 Provides acceptable written documentation of the overall discharge plan including revisions congruent with time frames established by department policy.
6.5 Conducts and/or coordinates a discharge planning conference with the patient and/or family and relevant team members as appropriate prior to discharge.

7. Coordinates discharges to special placements such as alternative treatment or residential facilities nursing homes or hospitals.
7.1 Assess on a consistent basis the potential or projected need for special placements as part of the initial discharge planning evaluation as documented in the patients chart.
7.2 Monitors rehab progress on an ongoing basis for early identification of patients who may need alternative placement as indicated by documentation lack of progress and/or family issues/support.

7.3 Maintains current information files on special placements including type of program resources costs admission criteria and current availability.
7.4 Discusses placement options with patient and/or family in a timely manner as documented in the patients record and as reflected in satisfaction surveys.
7.4 Seeks recommendations from rehab team regarding any special placements that might be of benefit for the patient.
7.5 Documents the special placement process congruent with established department policies and procedures and the needs of the placement source.
7.6 Accomplishes effective timely placements as indicated by documentation in the patient record audits and feedback from patient satisfaction surveys.
7.7 Gathers followup information on all unusual placements (i.e. those with severe or atypical patient and/or family problems placements in settings not utilized before quality of care issues or issues identified on the patient satisfaction survey.
7.8 Ensures any special needs of the patient are properly arranged for according to department policy.

8. Communicates and consults regularly with the treatment team patient family payor source and community resources to ensure continuity of care and optimal benefit to the patient and family.
8.1 Demonstrates effective overall communication skills as indicated in comprehensive documentation and as reflected in positive feedback from team colleagues.
8.2 Responds promptly to request from the rehab team patient family payor physician and/or community resources on a consistent basis as observed by supervisor and as indicated by feedback.
8.3 Documents case management services and significant communication congruent with established department guidelines and as indicated by positive chart audits.
8.4 Consistently keeps all members of the team apprised of significant information and developments with respect to a patients case such that no delays in the treatment plan are experienced secondary to non or miscommunication issues.

9. Facilitates communication with insurance case mangers and representatives to coordinate the needs of the payor with those of the patient.
9.1 Initiates contact with the insurance case manager and/or utilization review personnel assigned to the case and determines the necessary information and frequency of reports required by the payor.
9.2 Updates the insurance company with appropriate information at the appropriate time interval.
9.3 Obtains recertification for continued services when appropriate and in a timely manner.
9.4 Communicates information to the physician patient and/or family and treatment team with regards to insurance coverage limitations etc.
9.5 Relates in a timely manner recertification information to the business office via established department procedure.
9.6 Demonstrates knowledge of current contractual arrangements and manages related cases congruent with parameters.
9.7 Completes insurance logs in a timely manner and with detailed information regarding communication with insurance case managers.

10. Facilitates and coordinates referrals for services relevant to the social educational vocational medical and other psychosocial needs of the patient and/or family.
10.1 Provides through assessment of potential referral needs as documented in the patient record.
10.2 Demonstrates a working knowledge of available community resources that assist or meet the patient and/or familys needs as expressed through patient satisfaction and successful documentation.
10.3 Seeks and integrates input form the patient family and rehab team concerning referral needs as documented in the patient record.
10.4 Facilitates referrals for services that offer appropriate aid to meet the patient and/or familys needs.
10.5 Demonstrates working knowledge of available services within the continuum and encourages utilization when appropriate to enhance continuity of care.
10.6 Documents referrals congruent with established department procedure on a consistent basis as indicated by positive results from chart audits.

11. Coordinates all durable medical equipment / supplies which has been recommended for home use for
all patients in Fraziers inpatient and outpatient programs.
11.1 Collaborates with the treatment team to determine recommended home equipment needs.
11.2 Selects appropriate vendor based on patient physician or insurance preference.
11.3 Provides vendor with necessary information to properly fill equipment needs.
11.4 Ensures all necessary signatures from physicians are obtained before ordering equipment.
11.5 Documents ordering of equipment as outlined in departmental policy and procedures.
11.6 Ensures that the patient and/or family have information on which vendor the equipment was ordered from should they have questions.

12. Serves as patient advocate to ensure all patient concerns are addressed.
12.1 Demonstrates working knowledge of facility and department policies for addressing patient/
family concerns.
12.2 Works to ensure that all patient/family concerns are addressed in a timely manner.
12.3 Consults with supervisor when significant uncertainties arise about ethical issues.
12.4 Demonstrates knowledge and awareness of the Ethics Committee and makes appropriate
as appropriate via supervisor.
12.5 Documents patient/family concerns and subsequent resolutions such that they may be reviewed
for process improvement.

13. Demonstrates commitment to continuing professional personal and program development.
13.1 Reviews current literature regarding case management trends health care reform specific
program articles as they relate to SCI TBI CVA etc. and help educate the treatment team on new trends and methodology.
13.2 Seeks personal and professional growth through the utilization of educational seminars.
13.3 Reviews the Policy and Procedure Manual and specific Program policies on an annual basis and provides input for revisions and Quality Improvement opportunities within the department and assigned patient programs.
13.4 Participates in hospital wide CQI teams as indicated.13.5 Demonstrates openness to guidance correction and constructive feedback.
13.6 Attend hospital FIMS training and is successful in passing the InterRater Reliability Test and recertifications.
13.7 Participates in weekly/monthly meetings to assigned responsibilities i.e. Brain Injury Task Force SCI Task Force CVA Task Force etc.
13.8 Seeks opportunities to establish linkages with professional organizations to develop personal expertise and to maximize opportunities for patients.
13.9 Carries out assigned committee tasks and responsibilities within established time frames and in a professional manner.
13.10 Demonstrates knowledge of facility Environment of Care Plan as it relates to the following:
Safety
Life Safety
Security
Emergency Preparedness
Hazardous Materials
Equipment Management
Utilities Management

Education: Bachelors or Masters Degree in Social Work required

Required Experience: Five years minimum of case management experience in a rehab setting preferred. Experience with patient/family counseling and problem resolution preferred. Knowledge of Medicare Medicaid and Third Party Payor systems.

Licensure: Kentucky licensed Social Worker

Special Skills Required: Excellent communication skills; excellent psychosocial assessment skills. Short term crisis intervention skills. Understanding of medical terminology. Previous insurance experience. Ability to work well under stress.

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