Discharge & Care Coordination Case Manager

Community Health Network; Indianapolis (IN); On-site; USD 52,000 - 75,000; Full time

Job summary

Community Health Network is seeking a Case Manager to oversee assessment, planning, implementation, coordination, monitoring, and evaluation of services across the continuum of care to ensure quality patient outcomes and appropriate utilization of health care services.

The role emphasizes discharge planning, collaboration with the healthcare team, and guiding patients and families through transitions in care, while adhering to Medicare/Medicaid guidelines and hospital policies.

Qualifications

• LCSW or LSW in the State of Indiana required.
• Master’s Degree in Social Work required.
• 2+ years of inpatient, outpatient, or home-based social work experience required.
• Experience with quality improvement methodology preferred.
• Demonstrates support of the hospital vision/mission statement.

Responsibilities

• Collaborate with the healthcare team to coordinate discharge planning and ensure timely, safe transitions of care.
• Conduct comprehensive discharge planning assessments and establish discharge plans with the patient, physician, and care management team.
• Implement discharge plans, including referrals to home health agencies, transportation, and addressing unmet needs to ensure safe transitions to the next level of care.
• Proactively communicate with nursing staff and ancillary departments regarding ongoing discharge plans, barriers, or delays.
• Develop goal-directed plans of care based on intermediate goals and specific outcome criteria.
• Coordinate and facilitate care in a knowledgeable, skillful, and consistent manner.
• Document patient records in a timely, accurate, clear, and concise manner within the transition to quality software.
• Record pertinent data in required areas to enable efficient, continuous care by the team.
• Demonstrate awareness of patients’ rights and maintain sensitivity to patients and significant others within institutional values.
• Apply knowledge in care decisions for designated patient populations and seek guidance when needed.
• Demonstrate accountability for own professional practice and participate in staff development activities for the care management team and nursing staff.
• Collaborate with nurse case manager on discharge planning and use of clinical pathways.
• Engage in ongoing professional development and continuing education to meet development goals.
• Understand legal issues related to patient care and unit function; participate in risk-reduction activities.
• Contribute to the development and evaluation of care management team functions; participate in meetings, reports, and related activities.
• Communicate effectively using appropriate lines of authority.
• Conduct and utilize discharge planning assessments that ensure continuity of care for patients.
• Act as a liaison to post-hospital care providers and community health resources; advocate for patients and families.
• Demonstrate knowledge of Medicare, Medicaid, and third-party payer guidelines; complete all necessary paperwork for final disposition.
• Facilitate personal interviews with patients and family conferences to inform discharge plans; coordinate multidisciplinary input as needed.

Skills

Discharge planning

Collaboration with healthcare team

Documentation

Communication

Education

Master's Degree in Social Work

Job description

Community Health Network is seeking a Case Manager to oversee assessment, planning, implementation, coordination, monitoring, and evaluation of services across the continuum of care to ensure quality patient outcomes and appropriate utilization of health care services.

The role emphasizes discharge planning, collaboration with the healthcare team, and guiding patients and families through transitions in care, while adhering to Medicare/Medicaid guidelines and hospital policies.