To the staff: Just a short note to say “thank you” for taking care of Mary Lou these past years. I know at times it wasn’t easy, but she went the way she would have wanted. The funeral was just as I would have liked, and I know Mary Lou was happy with it. Again, many thanks, Geri + Denny F. and the H. Family

Port Healthcare Center

Case Manager - RN 32 hours

Location: Bradford, MA - Whittier Rehabilitation Hospital

Category: Social Work

Case Manager - RN 32 hours

Primary Responsibilities:
• To oversee and coordinate each patient's care, from admission through post discharge follow-up by working with the members of the interdisciplinary team to provide the optimum rehabilitation services in the most efficient manner.
• Meet with every patient/family to introduce case management and begin an assessment of potential discharge planning needs. Take into account patient’s age and developmental level, cultural and religious practices, language and emotional barriers, healthcare needs, financial situation and family/community support.
• Provide the patient and family information, in a form that they can understand, about the rehabilitation process, levels of care, homecare services, community resources and patient rights including Advance Directives.
• Attend all interdisciplinary team meetings (RTC, FTC, TTC) to collaborate with the healthcare team, patient and family to establish a treatment plan with realistic goals and target date to achieve the goals. Identify variables that may influence the accomplishment of the goals. Continually evaluate the effectiveness of the plan and modify as needed.
• Collaborate with the healthcare team, patient and family for a timely discharge to the next level of care, when appropriate. Assist the team in identifying agencies or facilities that can meet the patient’s healthcare needs
• Make referrals to the next level of care and coordinate the transfer to maintain a continuation of services. Counsel with the patient/family and the payor to coordinate funding for the services. Obtain approval numbers from payor, if needed.
• Organize all referral paperwork needed to make discharge referral, review for completeness and fax (or have faxed) to the agency or facility that will continue to provide service.
• Maintain patient privacy and confidentiality at all times. Release only information authorized by the patient/responsible party, and only the specific information required. ­ Case managers will act as utilization review coordinators.
• Refer any cases requiring medical judgment to a physician advisor.
• Maintain timely contact with external case managers and third party payors as required under “continued stay review” programs. Obtain approvals for continuation of the treatment plan. Advocate for services at an appropriate intensity to best meet the patient's needs.
• Notify members of the team and business office of any exclusions or level of care changes.
• Keep patient and family informed of Utilization Review decisions and provide discharge planning options to meet patient care needs.
• Document all case management activities in the patient’s medical record, including notes related to conversations with patient/family, insurers and others in accordance with laws, regulations and hospital policy.

• Registered Nurse with a minimum of 5 years varied nursing experience, preferably orthopedic, med­-surg, geriatric or rehabilitation. Case management experience preferred.
• Excellent communication (written and verbal), interpersonal and organization skills.
• Ability to assess, analyze, plan, implement and evaluate.
• Basic knowledge of insurance, including an understanding of eligibility, benefits and limitations.
• Knowledge of growth and development across the life span.

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