Rehabilitation Case Manager

County of Santa Clara; California (MO); On-site; USD 90,000 - 120,000; Full time

Job summary

County of Santa Clara is seeking licensed rehabilitation professionals (RN/OT/PT/SLP/CSW) to assess, plan, coordinate, implement, and monitor medical services for patients across SCVMC facilities. Applicants must hold California licenses and may work across multiple sites, including Santa Clara Valley Medical Center, O'Connor, St.

Louise, Regional Medical Center, and beyond. Roles involve coordinating care, liaising with multidisciplinary teams, and facilitating discharge planning.

Qualifications

• Possession of a valid California license: RN, OT, PT, SLP, or CSW issued by the California Department of Health Services prior to appointment.

Responsibilities

• Reviews patient charts for adherence to treatment plans and monitors progress.
• Serves as liaison with staff of various disciplines to ensure timely care and discharge planning.
• Directs resources and coordinates care plans with payers and providers.
• Documents patient progress and assists in community paperwork as needed.
• Participates in case conferences, huddles, and interdisciplinary rounds.

Skills

Communication (oral & written)

Interdisciplinary collaboration

Independent work under pressure

Job description

Under limited direction, to assess, plan, coordinate, implement, facilitate, and monitor the delivery of required medical services, treatments, and resources for assigned patients of the Rehabilitation (Rehab) Services at Santa Clara Valley Medical Center (SCVMC).

Only applicants who provide proof of active Registered Nurse, Occupational Therapist, Physical Therapist, Speech Language Pathologist, or Clinical Social Worker license, issued by the State of California, Department of Health Services certificate attached to their application will be accepted. All other applicants will be rejected.

The established list may be used for full-time/part-time/extra help/pm shifts/weekends vacancies as they occur.

Because we serve patients throughout multiple hospitals and clinics, you may have to work at different sites. We will meet any obligations we may have when this occurs.

The Power of WE

Together, we can make a greater impact. Bringing better care and expanding healthcare services across the community.

Santa Clara Valley Healthcare (SCVH) is the second largest public health care system in California and includes three acute care hospitals, 14 clinics and 60+ specialty and sub-specialty services. Our mission is to provide high-quality, accessible healthcare and excellent service to everyone in Santa Clara County.

Because we serve patients throughout multiple hospitals and clinics, you may have to work at different sites. We will meet any obligations we may have when this occurs.

Santa Clara Valley Medical Center

SCVMC is a full-service tertiary acute care teaching hospital with 699 licensed beds providing a wide range of specialized services, including Rehabilitation, Burn, Trauma, and NICU. SCVMC was ranked by U.S. News and World Report as #6 Rehabilitation Hospital in the nation and #1 in the West and designated as a 2024 High Performing hospital for Maternity Care, Heart Failure, Stroke, Hip Fracture, and Pneumonia.

O'Connor Hospital

O'Connor Hospital (OCH) is a 358 licensed bed acute care facility offering a full range of inpatient and outpatient medical, surgical and specialty programs to residents of Santa Clara County. It was founded in 1889 as one of the first hospitals in the county. OCH has grown significantly over the past five years in both its inpatient volume and its Emergency Department visits. Along with these volume increases other ancillary and clinical departments like imaging, lab, pharmacy, and respiratory have seen growth as well.

St. Louise Regional Hospital

Since 1989, St. Louise Regional Hospital (SLRH) has been caring for the residents in Santa Clara and San Benito Counties, offering a wide range of inpatient and outpatient medical specialties. SLRH has 93 beds, is a Designated Primary Stroke Center, and is the only acute care hospital in the area. Located in Gilroy, SLRH maintains a CALSTAR 2 emergency helicopter base on the premises.

Regional Medical Center

Regional Medical Center (RMC) is a 258-bed hospital that is the main emergency healthcare provider for East San José, treating a wide range of critical and life-threatening conditions for more than 60 years. Since the SCVH integration of RMC effective 4/1/25, RMC has expanded the critical services including Level II trauma, Thrombectomy capable Stroke Center and STEMI care, and has been seeing an increased number of emergency visits and inpatient volume.

Learn more about Santa Clara Valley Healthcare: https://www.scvh.org/home and follow us on: LinkedIn www.linkedin.com/company/county-of-santa-clara/ Facebook | www.facebook.com/sccjob Instagram| www.instagram.com/sccjobs/ Newsletter Subscription | Sign Up

• Reviews and assesses assigned patients' medical and personal history, current status, psychological needs; diagnosis, prognosis, treatment plan and payer source, including patients with complex discharge planning needs;
• Interviews patient, family, and/or caregivers regarding home environment and support, prior level of function, financial resources, social supports and other factors likely affect care and/or discharge plan;
• Provides medical treatment education to patient, patient's family and other medical staff;
• Reviews and assesses, on an ongoing basis, assigned patients' charts for adherence to treatment plans;
• Monitors progress of patient treatment and services;
• Acts as a liaison to and confers with staff of various disciplines to ensure completion of services and treatments with appropriate timeframes;
• Secures and negotiates for resources to ensure multiple health care needs are met;
• Identifies and resolves situations and barriers causing delays in service, treatment, or discharge; and utilizes creativity in developing solutions;
• Researches and recommends, when appropriate, alternative, more cost-effective service delivery;
• Communicates with and acts as a contact with payer sources for initial hospital authorization; justifies, advocates, and negotiates with payers on behalf of patients;
• Confers with appropriate individuals regarding patient treatment and service aspects in other specialty areas;
• Documents patient progress and other relevant patient information, and may assist in creating patient community paperwork;
• Participates in case management departmental meetings;
• Plans, facilitates and participates in interdisciplinary team conferences and huddles, family conferences, transition of care meetings, and patient rounds as needed;
• Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services and other healthcare providers and agencies; identifies potential difficulties in community reintegration where appropriate;
• Collaborates with payers and ancillary staff to ensure that medical equipment and supplies are procured, and training provided for timely and safe discharge;
• Researches criteria within utilization computer system in order to monitor patient level of care and to facilitate and assist doctor-to-doctor and peer-to-peer review between Hospital and health plan;
• Drives to medical facilities within assigned territory to assess appropriateness of patients in critical care settings for admittance to SCVMC's rehab services, and to provide information regarding rehab services offered by SCVMC;
• Following patient assessment, denies or recommends admission to SCVMC for patients from outside medical facilities;
• Acts as a resource for medical community facilities to assist in placing acute patients into an appropriate level of care, and possible future admittance to SCVMC rehab services;
• For patients being admitted to SCVMC from other facilities, prioritizes admissions based on patient assessment, procures insurance/payer authorizations; procures transportation, monitors transport and notifies admitting physician of changes and delays, and reprioritizes patients as necessary;
• Builds relationships with and markets SCVMC rehab services to other medical facilities;
• Makes formal and informal presentations regarding SCVMC rehab services;
• Assists with coordinating follow up therapist and specialty appointments, as necessary;
• Serves as a resource for expected length of stay for targeted diagnosis case mix group;
• Serves as member of various hospital committees and special events;
• Keeps abreast of payer guidelines and specific licensure requirements;
• Assists in the hiring process and training of new staff;
• Participates in special project development and implementation;
• May be assigned as a Disaster Service Worker, as required;
• Performs other related duties as assigned.

Sufficient education, training and experience to demonstrate possession and direct application of the following knowledge and abilities.

Training and Experience Note

The required knowledge and abilities are attained through two (2) years of full-time, journey level experience in the area of licensure, in an acute rehabilitation setting, including experience in assessing patient and family rehab needs and developing care plans.

Special Requirements

Possession of a valid Registered Nurse, Occupational Therapist, Physical Therapist, Speech Language Pathologist, or Clinical Social Worker license, issued by the State of California, Department of Health Services prior to appointment.

Ability to travel to alternate locations in the course of work is required for some positions. If driving, possession of a valid California Driver's License prior to appointment and the ability to qualify for and maintain a County driver authorization.

Possession of current patient case management experience is desirable.

Knowledge of

• Medical terminology used in diagnosis, level of care, disease continuum, and treatment;
• Patient evaluation, assessment and communication techniques;
• Various acute rehab care specialties;
• Basic training techniques;
• Federal and State health care laws and regulations appropriate to the operation of California hospitals;
• Financial processes of various private and public funding sources;
• Private and governmental insurers and medical assistance programs;
• Record keeping and reporting procedures;
• Available alternative patient services and treatment;
• Computer systems that provide evidence-based clinical criteria and common office computer applications;
• Various criteria for determining level of care and current standards in medical, therapy, and nursing practice.

Ability to

• Communicate orally and in writing in an effective, tactful, and assertive manner, including with distressed or emotional individuals;
• Keep abreast of, understand, and interpret healthcare laws, regulations, and procedures;
• Work independently and under pressure, meet deadlines, adapt to varying circumstances and use sound judgement in the performance of duties;
• Develop and maintain effective working relationships with patients, families, peers, medical professionals, and all contacted in the course of work;
• Reason logically and creatively, and utilize a variety of analytical techniques to resolve complex and specialized issues;
• Educate and train others;
• Perform research, evaluate data, and make recommendations;
• Work effectively and in cooperation with other organizations, departments and personnel;
• Keep abreast of available alternative treatments and services;
• Resolve complex interdisciplinary problems in an expeditious and effective manner.

Ability to work irregular hours, weekends, and holidays, as necessary.