Reports to the Manager, Case Management. Meets with patients/family/significant other to assess post hospital needs and facilitates linkage with appropriate community services and resources. Ensures patients have a well-planned process in place from admission to discharge or transfer of care for medically complex patients. Collaborates with the interdisciplinary team to assess clinical readiness for transfer and discharge. Ability to communicate positively and effectively with all levels of participants in health care delivery in both formal and informal settings and with individuals as well as groups of varying size and through documentation. Clinical expertise appropriate for designated patient population. Nurse Case Manager and Clinical Social Worker work together to identify complicated social and medical situations and provide interventions necessary for patient based on assessed needs. Skill in auditing outcomes concurrently and retrospectively. Capable of managing complex workload and establishing priorities. Maintains up-to-date knowledge of reimbursement processes and community resources. Provides clinical and discharge data necessary to insurance companies to ensure that post discharge needs are addressed.

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

• Continually assesses total population in assigned area re: discharge planning needs and LOS, social and financial needs.
• Completes assessments on admission and through discharge.
• Responds in a timely fashion to referrals for case manager intervention.
• Assesses overall process of referrals on assigned units and recommends interventions to improve whenever appropriate.
• Meets with patients/families/significant other and develops assessment of post hospital needs and services.
• Documents patient assessment promptly and completely.
• Works with patient and family to provide necessary education and facilitation of linkages with community services and resources.
• Provide information for support, advocacy and rights as needed for patient and family.
• Provides/refers for financial counseling as appropriate.
• Provides interventions for patients to ensure compliance such as Meds to Beds, vouchers, home health care.

• Develops in conjunction with other disciplines and in a timely fashion appropriate discharge plan.
• Investigates availability of community resources and presents recommendations to physician/patient/family/significant other.
• Documents patients/family understanding acceptance of/or alternatives to discharge plan on Discharge Planning Record.
• Facilitates referral/contact with appropriate resources to meet discharge needs.
• Demonstrates effective problem solving in conflicts or complex discharge planning situations.
• Leads efficient, effective routine discharge planning meetings and other conferences R/T the facilitation of discharge planning. Participates in rounding or discharge planning meetings with physicians and other team members.
• Schedules conferences between the patient/family and physicians and other disciplines as appropriate.
• Discusses obstacles to goal attainment with patient/family and providers and advocates for problem resolution.
• Assists nursing and physicians to facilitate transfers to other acute care hospitals.
• Works effectively with medical staff to optimize appropriate resource management.
• Advocates for patients with payers to obtain coverage for needed services.
• Ensures all mandatory Medicare notices are delivered and signed.
• Demonstrates understanding of insurance and managed care processes.

• Serves as resource to patient/family/significant other/staff and physicians re: community resources and post-acute services criteria.
• Identifies psychosocial and environmental needs related to admission, treatment and discharge.
• Provides information on financial resources, healthcare benefits.
• Demonstrates appropriate knowledge base and skill R/T handling of special situations i.e., child protective services, adoptions, adult protective services, Level II's, etc. Provides intervention as needed.
• Cross trains effectively to various units and functions within the department as assigned.
• Requires a thorough knowledge of community agencies, services, entitlement programs, and financial resources available on a federal, state and local level to assist patients and families.

• Completes other job-related duties and projects as assigned.
• Demonstrates a positive team approach to patient and departmental issues.

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

• The knowledge, skills, and abilities as indicated below are normally acquired through the successful completion of nursing program from an accredited school of nursing with a current Indiana license to practice as a Registered Nurse, a Bachelor's (BSW) or Master's (MSW) of Social Work. A minimum of three to five years of job-related experience is required. After January 1, 2014, candidates are required to have or obtain a BSN within five (5) years of employment as a Registered Nurse or will have the option to become certified in their area of specialty. The certification must be maintained based off of accrediting body standards.

• Possesses outstanding interpersonal skills with focus on listening, assertion, conflict resolution and collaboration.
• Provides oversight of plan of care and discharge readiness.
• Identify psychosocial issues and collaborate with other team members.
• Possesses strong knowledge of medical and clinical processes. Develops clinical expertise appropriate for designated patient population.
• Provides ongoing focus for clinically and socially complex patients.
• Works with patient's families and other members of the healthcare team to assist in navigating the complicated service systems.
• Understands function of complex healthcare organization providing broad scope of services.
• Ability to communicate positively and effectively with all levels of participants in health care delivery in both formal and informal settings and with individuals as well as groups of varying size and through documentation.
• Verify and obtain mandatory Medicare notices.
• Capable of managing complex workload and establishing priorities.
• Maintains up-to-date knowledge of reimbursement processes and community resources.

• Complexity of workload and communications may involve mental stress.

• Requires the physical ability and stamina (i.e., to walk/stand for prolonged periods of time, push carts/wheelchairs up to 50 pounds, to position/lift patients at a maximum of 35 pounds unassisted, over 35 pounds requires assistance, provide CPR, etc.) to perform the essential functions of the position.