Case Management

2 weeks ago

San Francisco, CA, United States San Francisco Campus for Jewish Living Full time
On-Call

San Francisco Campus for Jewish Living

Nestled in San Francisco's Excelsior neighborhood on a nine-acre campus, the San Francisco Campus for Jewish Living (SFCJL) is a center of excellence in providing a continuum of care. This includes the Frank Residences, which offer luxurious assisted living and memory care services; the Jewish Home and Rehabilitation Center, featuring long-term skilled nursing, short-term rehabilitation, and an acute psychiatric unit specializing in mental healthcare for older adults (age 55 and over); and the Jewish Home and Senior Living Foundation.

Grounded in the Jewish values of dignity, compassion, and community, the San Francisco Campus for Jewish Living-fondly referred to in the past as "the Jewish Home"-was founded in 1871. Today, 150 years later, it continues to build upon its legacy of enriching the lives of older adults.

Position Overview:

The primary goal of this position is to enhance the quality of patient management and satisfaction, promote continuity of care, and ensure cost-effectiveness through the integration and coordination of case management, utilization review, and discharge planning. The Clinical Case Manager ensures patients progress through the continuum of care and are discharged to the least restrictive environment. This role provides ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. The Case Manager holds accountability for care coordination and discharge planning for all patients.

ESSENTIAL FUNCTIONS:
  • Coordinate the integration of case management and social services into the patient care, discharge, and home planning processes in collaboration with other departments, external organizations, agencies, and healthcare facilities.
  • Provide leadership, supervision, and support to nursing and care staff in delivering clinical and care support services in a professional manner.
  • Introduce self to the patient and family, explain the Clinical Case Manager's role, and provide contact information to facilitate communication.
  • Enable patients and families to participate in decisions about their health and care needs.
  • Act as a patient advocate; investigate and report adverse occurrences; provide staff education related to resource utilization, discharge planning, and the psychosocial aspects of healthcare delivery.
  • Facilitate interdisciplinary patient care rounds or conferences to review treatment goals, optimize resource utilization, provide family education, and identify post-rehabilitation transition needs.
  • Assist Social Services/Discharge Planner with care conferences.
  • Negotiate with service providers, payers, and members of the care team to meet patients' care needs (including labs, x-ray, pharmacy, rehab, ambulance, equipment, etc.).
  • Investigate and address concerns identified through the Rehab Post-Discharge Follow-up Program.
  • Oversee the completion of certifications/re-certifications, Generic Notices of Non-Coverage, Detailed Notices of Non-Coverage, and related documentation for Medicare and Managed Care.
  • Assist the MDS Nurse (Resident Assessment Coordinator) with completion of MDS assessments as needed.
  • Lead the daily pathway meeting with the Rehabilitation Director to determine the most appropriate Assessment Reference Date (ARD) that ensures optimal reimbursement. Lead the weekly Utilization Review meeting.
  • Communicate regularly with physicians during a patient's rehab stay to maintain appropriate cost control, case management, and desired patient outcomes.
  • Complete comprehensive assessments of patient and family needs at admission. Complete the Discharge Disposition Assessment and Discharge Management Calendar with the Discharge Planner weekly.
  • Conduct concurrent medical record reviews using indicators and criteria approved by medical staff, CMS, and other regulatory agencies.
  • Provide education, information, and guidance to patients and families in a supportive and understanding environment.
  • Maintain appropriate, legible documentation, records, and databases, and remain aware of the legal implications of all documentation.
  • Evaluate and improve existing nursing practices and clinical guidelines in consultation with staff, patients, and management.
  • Review utilization of services from admission through discharge to ensure appropriate resource use and timely achievement of clinical goals.
  • Perform other duties as assigned.
QUALIFICATIONS:
  • Graduate of an accredited School of Nursing; RN preferred.
  • Valid California RN license.
  • Minimum of one year of nursing experience in a long-term care environment preferred.
  • Strong knowledge of the RAI process, CMS, and state and federal regulations pertinent to Skilled Nursing Facilities (SNFs).
  • Ability to provide direction and coordination for a multi-faceted program and resolve facility-related issues.
  • Excellent organizational, interpersonal, and communication skills (both verbal and written).
  • Accurate, concise, and detail-oriented.
  • Self-motivated, able to work independently, and manage multiple tasks in a deadline-driven environment.
  • Proficient in computer skills, including email, internet usage, and word processing.

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