discharge planner

Southeast Health

<div><h1 class="jobSectionHeader"><b>Southeast. Always the right career direction.</b></h1><p></p><h2 class="jobSectionHeader"><b>
Job Description Summary</b></h2>
The Clinical Transition Coach (CTC) assists in the safe and timely transition of patients from acute inpatient care to alternative levels of care, including but not limited to a home care program, palliative/hospice program, skilled nursing facility, or home setting appropriate to the patient&rsquo;s needs. The CTC performs activities essential to the discharge of the patient, and may also assist with the admissions process and/or other processes to facilitate patient throughput.<h2 class="jobSectionHeader"><br>
<b>
Job Description</b></h2><h3 class="jobSectionHeader"><b>
QUALIFICATIONS:</b></h3><ul><li>
Current (unencumbered) LPN license in the state of Alabama;</li><li>
Minimum of 3 years nursing experience in a medical surgical setting</li></ul><p></p><h3 class="jobSectionHeader"><b>
LANGUAGE/ COMMUNICATION SKILLS:</b></h3><ul><li>
Ability to read, write, and speak English;</li><li>
Ability to communicate effectively with individuals of various educational levels and cultural backgrounds via written and verbal formats;</li><li>
Excellent customer service skills and interpersonal skills</li></ul><p></p><p><b>
SKILLS:</b></p><ul><li>
Annual completion of competency requirements;</li><li>
Experience in operating personal computers, including operation of computer software in a Windows environment;</li><li>
Must be able to work in a self-directed environment, with ability to work as an integral member of the healthcare team;</li><li>
Position requires excellent conflict resolution, problem solving, leadership, and organizational skills, as well as written, and verbal communication skills.</li></ul><h2 class="jobSectionHeader"><br>
<b>
Shift</b></h2>
Day<h2 class="jobSectionHeader"><b>
Shift Details</b></h2>
8:00 am - 4:30 pm<h2 class="jobSectionHeader"><br>
<b>
FTE</b></h2>
1<h2 class="jobSectionHeader"><br>
<b>
Type</b></h2>
Regular<h2 class="jobSectionHeader"><br>
<b><i>
Join one of Forbes 500 best mid-sized employers in America.</i></b></h2><h2 class="jobSectionHeader"><b><i>
Equal Employment Employer</i></b></h2><h2 class="jobSectionHeader"><b><i>
Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.</i></b></h2></div>

CTC- Discharge Planning

Wellstar Health System

<div><p>How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.</p><p></p><p><b>
Work Shift</b></p>
Day (United States of America)<p></p><p><b>
WellStar Kennestone Hospital has an opportunity for a Care Coordinator (RN) - Weekend</b></p><p></p><p><b><br>
Part Time - Day Shift - Weekend Only (Friday, Saturday, and Sunday Only)</b></p><p><b>
8:30AM to 5:00PM</b></p><h2 class="jobSectionHeader"><b>
Job Summary:</b></h2><p></p><p><br>
The Care Coordinator RN (CC RN) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. The CC RN plans effectively to meet the patient's needs, manage the length of stay and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions.<br>
Specific functions within this role include:<br>
Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education<br>
Collaborates effectively with the utilization review nurse, patient's physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needs<br>
Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers<br>
Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.<br>
May have other duties assigned</p><p></p><h2 class="jobSectionHeader"><b>
Core Responsibilities and Essential Functions:</b></h2><p></p><div><br>
Assessment<br>
<ul><li>Based on preliminary screening of patients, initiates assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.</li><li>Partners with the PAS, financial counselor and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.</li><li>Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans..</li><li>Meets with physicians and care team routinely to collaborate on timely and efficient patient management.</li></ul><br>
Disposition Planning<br>
<ul><li>Manages all aspects of discharge planning for assigned patients.</li><li>Implements discharge planning timely and provides resources in an efficient manner.</li><li>Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.</li><li>Identifies and documents barriers for timely disposition.</li><li>Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.</li><li>Responds to referrals for patients post-acute needs from physicians and the care team.</li><li>Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.</li><li>Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.</li><li>Refer appropriate cases for social work intervention based on departmental protocol.</li><li>Allows for any cultural or religious beliefs in providing service and continuity of care.</li></ul><br>
Care Progression<br>
<ul><li>Collaborates with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.</li><li>Proactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.</li><li>Identities and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.</li><li>Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution</li></ul><br>
Documentation<br>
<ul><li>Initial clinical/psychosocial assessment completed and documented in medical record.</li><li>Ensure all records are up-to-date and documentation is clear and concise.</li><li>Ensure timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team, and community partners as it pertains to the patients discharge plan.</li><li>Accounts for and indicates all services arranged/delivered in electronic medical record.</li><li>Track avoidable days and report trends that lead to undesired outcomes.</li></ul><br>
Professional Development and Initiative<br>
<ul><li>Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.</li><li>Supports department-based goals which contribute to the success of the organization.</li><li>Serves as a preceptor and/or mentor for student interns (if appropriate)</li></ul><br>
Performs other duties as assigned<br>
<br>
Complies with all Wellstar Health System policies, standards of work, and code of conduct.</div><p></p><h2 class="jobSectionHeader"><b>
Required Minimum Education:</b></h2><p></p><p><br>
Associate's Degree in Nursing from an accredited school of nursing with a Georgia RN License Required</p><p></p><h2 class="jobSectionHeader"><b>
Required Minimum License(s) and Certification(s):</b></h2><p><br>
All certifications are required upon hire unless otherwise stated.</p><p></p><ul><li>
Reg Nurse (Single State) or RN - Multi-state Compact</li><li>
Basic Life Support or BLS - Instructor</li></ul><p></p><h2 class="jobSectionHeader"><b>
Additional License(s) and Certification(s):</b></h2><p></p><h2 class="jobSectionHeader"><b>
Required Minimum Experience:</b></h2><p></p><p><br>
Minimum 1 year nursing experience in the acute care setting. Required</p><p></p><h2 class="jobSectionHeader"><b>
Required Minimum Skills:</b></h2><p></p><p><br>
Excellent written and verbal communication skill.<br>
Must possess maturity, self-confidence, objectivity, and positive attitude.<br>
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment<br>
Strong assessment, interview, organizational and problem-solving skills.<br>
Knowledge regarding local, state and federal regulations required.<br>
Knowledge of community and state-wide resources and programs.<br>
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist with progression of care through their transition to the next level of care.</p><p></p><p>
Join us and discover the support to do more meaningful work&mdash;and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.</p></div><p></p>

Care Coordinator (RN) - Part-Time/Rotating Weekends

Brown University Health

<div><ul><li>Job ID: JR-108277
</li><li>Entity: Rhode Island Hospital
</li><li>Location Name: Rhode Island Hospital
</li><li>City, State: Providence, RI
</li><li>Work Type: FULL TIME
</li><li>Hours Per Week: 36
</li><li>Shift: Day
</li><li>Posted Date: 4/11/2026
</li></ul><div><h2 class="jobSectionHeader"><b>SUMMARY</b></h2>
<p>
Reports to the Manager or Director of Case Management. Provides coordinated care support to facilitate and expedite patient care services. Participates in daily rounds and collaborates with the clinical healthcare team across the patient care continuum to include preadmission and post hospital discharge. As a member of that team, shares responsibility for the implementation of the discharge plan; ensures efficient and effective delivery of patient care services through the appropriate utilization of healthcare resources.</p>
<h2 class="jobSectionHeader"><b>
RESPONSIBILITIES</b></h2>
<ul>
<li><p>Partners with medical staff and other members of the healthcare team in collaboration with the patient/family to facilitate the plan of care for a defined patient population across the continuum of care. Identifies a high-risk patient population within the caseload for care management assessment screening and targets interventions in conjunction with the healthcare team within one business day of patient admission.</p>
</li>
<li><p>Participates in daily care rounds to collaborate with members of the patient's healthcare team as well as to evaluate and facilitate development and implementation of the discharge planning process. Develops the initial patient discharge plan and reviews with patient, family members and other members of the interdisciplinary team. Reassesses the discharge plan daily during collaborative care rounds.</p>
</li>
<li><p>Proactively builds post hospital referrals and sends to the Transition Care Coordinator when indicated to facilitate timely discharge.</p>
</li>
<li><p>Delivers Important Message follow-up notices to all Medicare patients according to CMS regulations. Follows CMS and DOH regulations in relationship to discharge guidelines and patient rights.</p>
</li>
<li><p>Coordinates the length of stay with the physician care team and patient. Ensures team is informed of insurance qualifiers that may affect the discharge plan. Discuss approaching discharge readiness of patients. Identify and assess readmitted patients and complex patients in collaboration with members of the healthcare team to coordinate discharge.</p>
</li>
<li><p>Advocates for the patient and advises the patient regarding financial implications of their discharge plan when coordinating care for the patient. Communicates the discharge plan, including post facility acceptance, to patients, families and all members of the care team.</p>
</li>
<li><p>Documents final discharge disposition in progress notes. Develops appropriate patient care reports to ensure safe patient handovers occur as a patient is transferred from one patient care area to the next. Provides care plan direction for the advancement of a patient care delivery system which supports managed care strategies and decreases readmission risk.</p>
</li>
<li><p>Acts as a change agent by identifying opportunities to improve patient flow and reduce service delays through problem resolution and follow-up.</p>
</li>
<li><p>Demonstrates a fundamental grounding in nursing theory and practice with a clinical background within a defined content area. Remains current on the latest concepts techniques and methods relative to his/her service.</p>
</li>
<li><p>Demonstrates knowledge of federal and state rules and regulations.</p>
</li>
<li><p>Reviews and acts as a change agent by identifying opportunities to improve patient flow and identifies and reduces service delays through problem resolution and follow-up. Identifies and tracks service and discharge patient delays.</p>
</li>
<li><p>Participates in departmental and/or interdepartmental quality improvement activities as requested: i.e. OpX teams weekly long LOS reviews interdisciplinary rounds readmission reviews. Participates in Orienting of New staff as requested.</p>
</li>
<li><p>Participates in ongoing education-related professional activities and affiliations to maintain an advanced level of knowledge of patient care services third party payer and managed care requirements and case management.</p>
</li>
</ul><h2 class="jobSectionHeader"><b>MINIMUM QUALIFICATIONS</b></h2>
<p>
Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.</p>
<h2 class="jobSectionHeader"><b>
BASIC KNOWLEDGE</b></h2>
<ul><li>Graduate of a School of Nursing with current license to practice as a Registered Nurse in the State of Rhode Island.</li>
<li>Bachelor's Degree Required.</li>
<li>Certification in Case Management by a nationally recognized organization preferred.</li>
<li>AHA BLS Provider Required.</li>
</ul><h2 class="jobSectionHeader"><b>EXPERIENCE</b></h2>
<p>
Three years of clinical experience with recent experience in case management, community case management, patient navigation, or discharge planning is strongly preferred. Strong analytical and interpersonal skills are required to provide guidance to and communicate daily with healthcare professionals, patients and families. Must exhibit a collaborative approach and method of communication to interact successfully on a daily basis with a wide and diverse population of both health care providers, insurers, patients and their families. Demonstrates knowledge and skills necessary to provide care to patients throughout the life span with consideration of aging processes, human development stages and cultural patterns in each step of the care process. Must be proficient in the use of Microsoft Office software including email and Outlook calendar and have basic keyboarding skills.</p>
<h2 class="jobSectionHeader"><b>
WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS</b></h2>
<p>
General hospital environment with occasional stressful conditions associated with patient care. Risk of exposure to blood borne pathogens and disease is minimized and controlled by adherence to Hospital Infection Control policy and procedures. Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means. Visual acuity and finger dexterity is needed to review and carry medical records, navigate through automated system screens and type on a typical computer terminal keyboard. Lifting of up to 10 lbs. may be necessary to transport items from one care unit to the next.</p>
<h2 class="jobSectionHeader"><b>
INDEPENDENT ACTION</b></h2>
<p>
Responds to individual patient-care situations demonstrating knowledge and skills acquired through education, certification and work experience.</p>
<h2 class="jobSectionHeader"><b>
SUPERVISORY RESPONSIBILITY</b></h2>
<p>
None.</p>
<h2 class="jobSectionHeader"><b>
Pay Range</b></h2>
<p>
$90,417.60 - $146,640.00</p>
<h2 class="jobSectionHeader"><b>
Location</b></h2>
<p>
Rhode Island Hospital - 593 Eddy Street Providence, Rhode Island 02903</p>
<h2 class="jobSectionHeader"><b>
Work Type</b></h2>
<p>
Monday - Friday 8-4:30; rotating weekends and holidays</p>
<h2 class="jobSectionHeader"><b>
Work Shift</b></h2>
<p>
Day</p>
<h2 class="jobSectionHeader"><b>
Driving Required</b></h2>
<p>
No</p>
<h2 class="jobSectionHeader"><b>
Union</b></h2>
<p>
United Nurses And Allied Professionals</p>
<p><i>
Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.</i></p></div></div>

Case Manager

Community Health Network

<div><div><div><div>Category</div>
<div>Nursing</div>
</div><div><div>Job Family</div>
<div>Case Manager</div>
</div><div><div>Department</div>
<div>Case Management</div>
</div><div><div>Schedule</div>
<div>Per Diem</div>
</div><div><div>Facility</div>
<div>Community Hospital South</div>
<div><div><div>1402 E County Line Rd</div><br>
<div>Indianapolis</div>, <div>IN</div> <div>46227</div><br>
<div>United States</div></div></div>
</div><div><div>Shift</div>
<div>PRN (as needed)</div>
</div><div><div>Hours</div>
<div>Variable</div><br>
</div></div><div><div><div><br>
<br>
<b>Join Community</b><br>
Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, &ldquo;community&rdquo; is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered &mdash; and we couldn&rsquo;t do it without you.<br>
<br>
<b>Make a Difference</b><br>
The Case Manager is responsible for the 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 Case Manager is responsible for supporting the healthcare team towards a smooth transition from one level of care to another in support of the patient/family.<br>
<br>
<b>Exceptional Skills and Qualifications</b><br>
Applicants for this position should be able to collaborate with others in a team setting, have excellent communication skills, and a positive attitude toward problem-solving.<br>
<br>
<ul><li>LCSW or LSW in the State of Indiana required.</li><li>Master&rsquo;s Degree in Social Work required.</li><li>2 + years of inpatient, outpatient, or home-base social work experience required.</li><li>Experience with quality improvement methodology preferred.</li><li>Demonstrates support of the hospital vision/mission statement.</li><li>Confers with nursing staff and other ancillary patient care departments regularly regarding ongoing discharge plans and barriers or delays.</li><li>Participates in developing and implementing the goal-directed plan of care, which is prioritized and based on intermediate goals and specific outcome criteria.</li><li>Coordinates and facilitates care in a knowledgeable, skillful, and consistent manner.</li><li>Performs documentation and patient records in a timely, accurate, clear, and concise manner in the transition to quality software.</li><li>Records pertinent date in required areas for other team members to provide care/services in an efficient, continuous manner.</li><li>Demonstrates awareness and sensitivity to the rights of patients/significant others, as identified within the institutional values.</li><li>Demonstrates sound knowledge base and actions in the care and decision making for designated patient populations and seeks guidance appropriately.</li><li>Demonstrates responsibility and accountability for own professional practice.</li><li>Participates actively in staff development activities for service line care management team, and nursing department personnel.</li><li>Collaborates with nurse case manager regarding discharge planning and use of the clinical pathways.</li><li>Demonstrates self-directed learning and participates in continuing education to meet own professional development.</li><li>Demonstrates awareness of legal issues in all aspects of patient care and unit function.</li><li>Participates in management of situations in a manner that reduces risk.</li><li>Participates in development and evaluation of the care management team functions.</li><li>Participates in meetings, reports, and other activities that support the care management team functions.</li><li>Demonstrates effective communication methods and skills, using lines of authority appropriately.</li><li>Conducts discharge planning assessments on identified patients that are consistent and provide for continuity of care for the patient.</li><li>Establishes the discharge plan with the patient, physician, and care management team for identified patients.</li><li>Implements the discharge plans for patients to include referrals to home health agencies return to ECF&rsquo;s transportation and any unmet needs to provide safe and appropriate transition to next level of care.</li><li>Demonstrates effective problem-solving techniques to communicate openly with members of the care management team and other staff.</li><li>Demonstrates skills as a resource and consultant to unit staff, care team members, and other staff.</li><li>Demonstrates skills as a resource and consultant to patients, families, and physicians.</li><li>Conducts effective problem-solving as a method of sound decision making.</li><li>Performs comprehensive assessment of patient/family goals as well as assessment of biophysical, psychosocial, environmental, financial, and discharge planning needs.</li><li>Procures services and serves as advocate on behalf of patients and families.</li><li>Acts as a liaison to post-hospital care providers and community health resources.</li><li>Demonstrates knowledge and understanding of Medicare, Medicaid, and third party payer guidelines.</li><li>Completes all necessary paperwork for final disposition.</li><li>Conducts personal interviews with patient, facilitates family conference and multidisciplinary conferences to formulate discharge plans.</li></ul></div></div>
<p><b>Why Community?
</b></p><p>At Community Health Network, we build teams that deliver exceptional care through empathy, communication and collaboration. We consider ALL an integral part of the exceptional patient experience. We PRIIDE ourselves on not having employees but Caregivers. Join our Community as we make a difference in your community.</p></div></div><p></p>

Case Manager- Licensed MSW- South- PRN

Ellis Medicine

<div><div><p><b>Friday, Saturday and Sunday 12-hour shifts.</b></p>
<p><b>Weekend Track</b></p><br>
<p></p>
<p>The RN Case Manager has responsibility for case management of assigned patients on a designated unit(s). This position works with the physicians and interdisciplinary team to facilitate and maintain compassionate, efficient quality care and achievement of desired treatment outcomes.</p>
<p>The Case Manager confirms admission and continued stay are medically necessary and ensures the interdisciplinary care plan and the discharge plan are consistent with the patient&rsquo;s required needs and covered services. Support services provided by the Case Manager include, but are not limited to, utilization review, case management, care transition, collaboration with physicians and social workers for care coordination and discharge planning.</p>
<p><b>EDUCATION AND EXPERIENCE REQUIREMENTS:</b></p>
<ul><li>Current license or valid permit to practice professional nursing in the state of New York</li>
<li>Associate&rsquo;s degree in nursing required, Bachelor's degree in nursing strongly preferred</li>
<li>Two years of inpatient experience in a hospital environment preferred.</li>
<li>Previous case management, utilization review, and discharge planning experience highly preferred. Home care, payer, or other experience will be considered.</li>
</ul>
<p><b>PHYSICAL REQUIREMENTS:</b></p>
<p>The position is located indoors and has community responsibilities to which the incumbent is required to attend. Should be able to push/pull 35 lb., lift/move 15 lb. from floor to table, be able to perform moderately difficult manual manipulations such as using a keyboard, writing and filing for extended periods of time, must be able to perform tasks which require hand-eye coordination such as data entry, typing and using photo copiers. Mobility requirements may include the ability to sit at a computer terminal or work station for a prolonged period of time, in addition to being able to squat, stand and walk for a reasonable length of time and distance and manual dexterity. Sensory requirements include the ability to articulate and comprehend the spoken English language in addition to being able to read the English language.</p>
<p><b>RESPONSIBILITIES OF THE POSITION:</b></p>
<div><ul><li><b>Discharge Planning:</b>
<ul><li>Meets with the patient and/or a family/personal representative as soon as possible, to assess, evaluate, and identify discharge needs.</li>
<li>Screens the patient for post-hospital needs throughout the continuum and makes appropriate referrals to those identified, as well as, the high risk population, chronic medical problems, non-compliance issues, interdisciplinary and/or patient's family requests.</li>
<li>Participates in interdisciplinary rounds, identifies anticipated discharge date and discharge plan, and promptly escalates barriers to leadership.</li>
<li>Acts as a role model, maintains professional standards and collaborates with patients, families, caregivers, interdisciplinary team members, external agencies, and insurance companies as needed to effectively execute discharge planning services, such as but not limited to: coordinating/leading team/family meetings, timely completion of NYS Peer Review Instrument and Screen, skilled nursing facility referrals and meetings, durable medical equipment referrals, ensuring completion of ambulance forms, discharge checklist and/or med-eval, etc&hellip;</li>
<li>Develops a comprehensive discharge plan and oversight of the assigned unit</li>
<li>Ensures that discharge planning plays a key role in the internal efficiency of the hospital by timely intervention for a low length of stay via identification of patient status &ndash; inpatient vs. outpatient/observation, resolving barriers to discharge, identifying and verifying payment source for services and equipment prior to implementation of the discharge plan</li>
<li>Collaborates and makes referrals to a physician advisor when unable to resolve issues with the attending physician.</li>
<li>Documents thoroughly and accurately in medical records</li>
<li>Collaborates with physician and other members of the interdisciplinary team to develop, plan, and facilitate a safe and realistic discharge plan, re-evaluating every 3 days or adjusting as a patient&rsquo;s condition changes throughout the patient&rsquo;s hospitalization.</li>
<li>Documents thoroughly and accurately in medical records</li>
<li>Identifies patients with complex discharge planning needs and complex psychosocial needs and coordinates transition of care with the Social Worker.</li>
<li>Serves as nurse consultant for Social Worker cases with clinical or discharge planning needs.</li>
<li>Coordinates acute hospital to hospital transfers to ensure compliance with all the discharge planning regulations and transfer policy</li>
<li>Provides guidance, support, and back-up to social workers on patients in need of transfer, medical review and care planning</li>
<li>Coordinates, plans, and participates in interdisciplinary discharge planning meetings, identifying barriers to discharge with participation of all disciplines.</li>
<li>Assures completion of discharge forms, i.e. Important Message from Medicare, PRI, and transportation within established timeframes and according to state/federal regulations</li>
<li>Adheres to the New York State Department of Health and Centers for Medicare and Medicaid Services discharge planning guidelines and departmental/organizational policies and processes</li><br>
</ul></li></ul></div><p></p><div><ul><li><b>Utilization Management:</b>
<ul><li>Ensures the order in the chart/EMR coincides with the InterQual review or CMS rules and regulations for the appropriate level of care and status on all patients through collaboration with the Utilization Review RN.</li>
<li>Contact the attending physician for additional information if the patient does not meet the appropriate InterQual guidelines or in accordance with CMS rules and regulations for continued stay.</li>
<li>Assesses and evaluates the medical necessity and appropriateness of ancillary testing, medications, treatment, and plan of care, discussing concerns with the involved physician, nurse or ancillary staff member. Make an appropriate referral to a physician advisor regarding trends/areas of concern</li>
<li>Proactively monitors patient activity, identifying and resolving delay and barriers to discharge. Monitors length of stay, readmissions, and documents avoidable days for trending and performance improvement purposes.</li>
</ul></li></ul><ul><li><b>Other</b>
<ul><li>Attends necessary in-services; seeks learning experiences and gathers medical/community knowledge as needed.</li>
<li>Perform other duties as assigned and as listed in department Roles and Responsibility Grids</li>
</ul></li></ul></div><p>Ellis Medicine is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, creed, color, religion, sex/gender, age, national origin, disability, genetic information, predisposition or carrier status, military or veteran status, prior arrest, or conviction record, marital or familial status, sexual orientation, transgender status, gender identity, gender expression, reproductive health decisions, or domestic violence victim status.</p>
<p><b>Salary Range:</b><b> </b><b>$38.59-$57.89/hour</b><b> </b>Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.</p></div><br>
Location: Ellis Medicine &middot; Case Management<br>
Schedule: Full Time (36 Hours), Days</div>

CASE MANAGER (INPATIENT UNITS)- Weekend Track

Banner Rehabilitation Hospital

<div>Overview:
<p><b>
Hospital Name: Banner Rehabilitation Hospital - Tucson</b><br>
<b><i>In Partnership with Select Medical</i></b></p><p><b><br>
Position:</b> Case Manager<br>
<b>Schedule: </b>Per Diem - Weekdays &amp; Weekends available</p><p></p><p><br>
Our Inpatient Rehabilitation Hospital is committed to providing exceptional and compassionate care to best address the medical, physical, emotional, and vocational challenges for individuals with brain injuries, spinal cord injuries, neurological disorders, orthopedic issues, amputation, and multiple traumas.</p><p></p><p><b><br>
Why Join Us:</b></p><ul><li><b>
Start Strong:</b> Extensive orientation program to ensure a smooth transition into our setting.</li><li><b>
Opportunity for Advancement: </b>Demonstrate your skills and dedication which could lead to potential full-time opportunities</li><li><b>
Foster Well-being: </b>We offer benefits which support the financial, work/life and emotional well-being of you and your family members. Part time/Per Diem positions are eligible for 401k based on reaching 1,000 hours within their first anniversary or subsequent calendar year.</li><li><b>
Your Impact Matters:</b> Join a team of over 44,000 committed to providing exceptional patient care</li></ul>
Responsibilities:
<div>
The Case Manager is responsible for the coordination of health care decisions by using a systematic approach to assure treatment plans that improve quality and outcomes, coordination of care across the continuum; promotion of cost-effective care within the allotted time frame; assuring payments of hospital-based services meeting patient-related utilization management criteria, and implementation of safe and appropriate discharge plans. The Case Manager assesses the psychosocial needs of the patient and provides intervention as part of the discharge planning process.</div><ul><li>
The primary job functions in Case Management include:</li><li>
Clinical Interventions/Discharge Planning</li><li>
Care Planning Management</li><li>
Fiscal Management</li><li>
Payer/Referral Management</li></ul>
Qualifications:
<p><b>
Minimum Qualifications</b></p><ul><li>
Current Licensure per state guidelines in clinical or related discipline OR a Bachelor's or Master's in a health or human services discipline.</li></ul><p><b>
Preferred Qualifications</b></p><ul><li>
Previous experience in Case Management and Discharge Planning preferred.</li><li>
CCM Certification Preferred.</li></ul>
Additional Data:
<p><i>
Equal Opportunity Employer/including Disabled/Veterans</i></p></div>

Case Manager- Per Diem

Hackensack Meridian Health

<div>Overview:
<div>
Our team members are the heart of what makes us better.</div><div><br>
</div><div>At <b>Hackensack Meridian </b><b><i>Health</i></b> we help our patients live better, healthier lives &mdash; and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It&rsquo;s also about how we support one another and how we show up for our community.</div><div><br>
</div><div>Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.</div><div></div><div><br>
The <b>Care Coordinator, Care Management</b> is a member of the healthcare team and is responsible for coordinating, communicating, and facilitating the clinical progression of the patient's treatment and discharge plan. Accountable for a designated patient caseload; assesses, plans, and facilitates with patients, families and the multidisciplinary team to meet treatment goals, expected length of stay, and arrange for the appropriate next level of care. Oversees interfacility transitions and handoff between acute and post-acute services</div>
Responsibilities:
<div>
A day in the life of a <b>Care Coordinator, Care Management</b> at <b>Hackensack Meridian Health</b> includes:</div><br>
<div></div><ul><li>
Assesses patients by screening for potential discharge needs regardless of race, age, sex, religion, diagnosis and ability to pay. Meets directly with patient/family to assess needs and develop an individualized care plan in collaboration with the physician and other members of the health care team.
</li><li>Facilitates communication and coordination between members of the health care team and involves the patient and family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the plan of care.
</li><li>Maintains current information of community resources and refers patients to those community resources appropriate for the patient's care. Consults with other community agencies and committees to identify potential resources to support patients and their families.</li><li>
Works collaboratively with all team members of the multidisciplinary and post acute care teams to secure timely and appropriate transitions to the next level of care.</li><li>
Develops a discharge plan, in collaboration with the patient and support persons, identifying goals that will provide maximum benefit for each patient. Ensures that the discharge plan meets the continuing care needs of the patient.</li><li>
Documents and communicates information to the multidisciplinary team in order to coordinate and maximize care. Ensures that the medical record reflects the education provided, coordination of services, referrals made and authorizations obtained.
</li><li>Participates actively on appropriate committees, workgroups, and or meetings.</li><li>
Identifies and refers quality issues for review to the Quality Management Program.
</li><li>Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact on discharge as well as length of stay in a timely manner, for discussion and resolution.
</li><li>Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plan, as needed. Ensures that the medical record reflects reassessment of the discharge plan at least weekly and upon any change in medical condition affecting the plan.
</li><li>Provides patients and families with resources and discharge options. Educates regarding the risks and benefits of discharge options and any available health care benefits.
</li><li>Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices)
</li><li>Utilizes social determinants of health screening tools and resources during each intake assessment.
</li><li>Collaborates with all members of the multidisciplinary team to support the following functions; crisis intervention, counseling support and referrals, abuse and neglect reporting, adoption planning, guardianship, psychosocial assessments, observation management, capacity management, hospital throughput.</li><li>
Referrals should be made to the following as required/needed: a. Acute rehabilitation facilities b. Sub- Acute rehabilitation facilities c. Long Term Care facilities d. Assisted Living facilities e. Adult day program f. Level 1/Level 2 PASRR screening g. EARC screening h. Home Care i. Hospice j. Durable medical equipment k. Transport l. Dialysis m. Financial assistance n. Medication assistance o. Palliative Care p. Boarding home placement q. Mental health services r. Homelessness placement s. Substance abuse placement t. Division of Child Protection and Permanency u. Adult Protective Services</li><li>
Maintains annual competencies and ensures training and continuing education of the team in applicable platforms. (Epic, Xsolis Cortex, BI, Google Suites)
</li><li>Other duties and/or projects as assigned.</li><li>
Adheres to HMH Organizational competencies and standards of behavior.</li></ul>
Qualifications:
<div><b>
Education, Knowledge, Skills and Abilities Required</b>:</div><ul><li>
BSN or BSN in progress and/or willing to acquire within 3 years of hire or transfer into the position; or Masters Degree in Social Work.</li><li>
Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.</li><li>
Excellent verbal, written and presentation skills.</li><li>
Moderate to expert computer skills.
</li><li>Familiar with hospital resources, community resources, and utilization management.
</li><li>Excellent written and verbal communication skills.
</li><li>Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.</li></ul><div><b>
Education, Knowledge, Skills and Abilities Preferred</b>:
</div><ul><li>Master's degree.
</li></ul><div><b>Licenses and Certifications Required</b>:
</div><ul><li>NJ Licensed Registered Nurse or NJ Licensed Social Worker or NJ Licensed Clinical Social Worker.</li></ul><div><b>
Licenses and Certifications Preferred</b>:
</div><ul><li>Care Management, CCMA or ACMA certification strongly preferred.</li></ul><div>
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
</div>Starting Minimum Rate: Minimum rate of $90,750.40 Annually Job Posting Disclosure: HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package. The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to: Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness. Experience: Years of relevant work experience. Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training. Skills: Demonstrated proficiency in relevant skills and competencies. Geographic Location: Cost of living and market rates for the specific location. Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization. Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered. Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts. In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.</div>

Care Coordinator, Care Management

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