Case Manager Specialist (Per Diem)- Post Acute Services

Montage Health; Pacific Grove (CA); On-site; USD 68,000 - 90,000; Part time

Job summary

Montage Health is seeking a Case Manager Specialist on a per diem basis to support discharge planning and transitions for patients in the Inpatient Rehabilitation Unit and Westland House. You will coordinate with nurses, therapists, social services, and providers to identify needs, arrange services and equipment, and track progress toward timely discharge.

The role emphasizes collaboration with an interdisciplinary team, patient families, and external partners, with documentation in the EMR and

Qualifications

• Discharge planning, care transitions, and post-acute services knowledge.
• Two years healthcare or case management experience preferred.
• Experience in acute-care hospital or post-acute setting preferred.
• Education and experience may be substituted per policy.

Responsibilities

• Coordinate discharge planning and transitions for IRU and Westland House.
• Gather living situation, barriers, and support needs from patients and families.
• Coordinate referrals for post-discharge services and equipment.
• Maintain documentation in the electronic medical record.
• Collaborate with interdisciplinary team and external providers.

Skills

Discharge planning

Care coordination

Interdisciplinary teamwork

Communication

EMR proficiency

Prioritization

Education

Bachelor's degree

Experience considered in lieu of degree

Tools

EMR systems

Job description

Welcome to Montage Health’s application process! Job Description:

Position Summary

Under the leadership of the Director and Assistant Director of Post-Acute Services, the Case Manager Specialist provides administrative and logistical coordination support for discharge planning and transition-of-care activities for patients and residents served by the Inpatient Rehabilitation Unit (IRU) and Westland House. The position works with patients, families, the interdisciplinary team, providers, payers, and community partners to identify discharge needs, address barriers, coordinate services and equipment, and support safe, timely transitions to the next level of care. The Case Manager Specialist provides administrative and coordination support.

Essential Duties and Responsibilities

Discharge Planning and Transition Coordination

• Initiate and maintain the administrative workflow supporting discharge-planning for assigned patients and residents, using information, recommendations and direction provided by licensed clinicians and the interdisciplinary team.
• Gather information from patients, families, significant others, providers, and the care team regarding living situation, available support, transportation, equipment, follow-up services, and potential barriers to discharge and communicate concerns to the interdisciplinary team.
• Coordinate administrative discharge arrangements for home, community-based services, outpatient therapy, home health, skilled nursing, long-term care, assisted living, or other settings as directed by the interdisciplinary plan of care.
• Track target discharge dates, required tasks, referrals, authorizations, appointments, and outstanding barriers; elevate delays or concerns to the appropriate licensed clinician or leader.
• Provide administrative support for transfers and discharges, including communication with receiving providers and confirmation that required arrangements are completed.

Interdisciplinary Collaboration

• Participate in IRU Patient Care Conferences, Westland House care conferences, discharge huddles, and other interdisciplinary meetings; communicate the status of discharge arrangements and identified barriers.
• Partner with nursing, therapy, physicians, social services, admissions, utilization management, pharmacy, and other disciplines to support an organized transition plan.
• Serve as a consistent point of contact for routine administrative coordination related to discharge and transitions of care among patients, families, the care team, and external agencies.
• Refer clinical questions, changes in condition, medical decision-making, and scope-restricted activities to the appropriate licensed professional.

Patient and Family Support

• Explain the discharge-planning process, services identified by the interdisciplinary team, and required next steps in a clear, respectful, and service-oriented manner.
• Coordinate patient and caregiver meetings, observations, training sessions, and follow-up communication as requested by the clinical team.
• Provide information about community resources, transportation, caregiver support, financial assistance programs, and insurance-related processes within the scope of the position.
• Document communications, preferences, barriers, and follow-up activities in the electronic medical record according to department standards.

Resource, Referral, and Equipment Coordination

• Process and track referrals for post-discharge services, including outpatient therapy, home health, durable medical equipment, transportation, and community programs, based on orders and recommendations from authorized clinicians.
• Communicate with vendors, facilities, insurers, and community providers to obtain information, confirm availability, and support timely service delivery.
• Assist with insurance verification, authorization follow-up, and identification of covered resources; elevate coverage issues that may affect the discharge plan.
• Confirm that ordered equipment, services, appointments, and required documentation are arranged before discharge, and promptly communicate unresolved issues.

Documentation, Compliance, and Administrative Support

• Maintain accurate, timely, and complete documentation of administrative transition planning activities, referrals, communications, and outcomes.
• Follow applicable organizational policies, privacy requirements, payer requirements, and regulatory standards for IRU and skilled nursing services.
• Collect and organize information needed for reports, audits, quality-improvement activities, and transition-of-care metrics.
• Provide administrative support to Post-Acute Services as assigned, including scheduling, record coordination, phone communication, and maintenance of resource lists and workflow tools.

Knowledge, Skills, and Abilities

• Knowledge of discharge planning processes, care transitions, community resources, durable medical equipment, and post-acute service options.
• Working knowledge of Medicare, Medi-Cal, commercial insurance, authorization processes, and financial reimbursement concepts preferred.
• Ability to review and organize information from diagnoses, treatment plans, functional recommendations, and anticipated outcomes without independently interpreting clinical findings.
• Strong interpersonal, customer service, public relations, and conflict-resolution skills.
• Ability to communicate clearly and professionally, verbally and in writing, with patients, families, staff, providers, payers, and community partners.
• Ability to prioritize multiple cases, meet deadlines, track details, and elevate barriers appropriately.
• Ability to work effectively across IRU and Westland House within an interdisciplinary team.
• Proficiency with electronic medical records, basic computer applications, and word processing.

Experience

• Two years of experience in healthcare, case management support, discharge planning, care coordination support, utilization management support, admissions, social services support, or a related field preferred.
• Experience in an acute-care hospital, inpatient rehabilitation facility, skilled nursing facility, or other post-acute setting preferred.
• Experience working with adults and older adults with medical, physical, cognitive, psychosocial, and functional needs preferred.

Education

• Bachelor's degree in a healthcare, social services, human services, or related field preferred.
• Equivalent relevant education and experience may be considered in accordance with organizational requirements.

Licensure/Certifications

• American Heart Association Healthcare Provider BLS certification required or obtained within the timeframe established by department policy.
• Additional credentials or training may be required based on organizational policy and assigned responsibilities.

Equal Opportunity Employer #LI-AC1

Assigned Work Hours: Per Diem Position Type: Per Diem Pay Range (based on years of applicable experience): $48.63 to $65.07 The hours employees work determine when a shift differential is paid. Hourly Evening Shift Differential: $2.99 Hourly Night Shift Differential: $4.48 Montage Health, a nonprofit company, is a collection — a montage — of entities designed to keep people healthy and connected. Preventive, restorative, palliative, and coordinated care. Many parts operating with a single, shared vision.