Care Manager Team Lead

Care Manager Team Lead

Schedule: .4 FTE; 16 hours/ week

Compensation: starting wage $32.05 (commensurate based on experience)

Summary:

Provides care management services to all patients and families to promote optimal functioning throughout the rehabilitation process. Maintains current with clinical practice through continuing education, research, and program development. In addition to the responsibilities of a Care Manager, the Care Manager Team Leader will provide input into the performance of the CM employees along with the Director of CM and disciplinary action planning when needed. The CM team lead provides daily oversight of the clinical aspects of the IP Care Management department to assure that safe, evidence-based care is provided to each patient served. Under the direction of the Director of Care Management, the team leader is responsible for the implementation of a patient-focused, team oriented culture, working in collaboration with all other medical, clinical and therapeutic disciplines to ensure optimal service and superior outcomes. The CM team leader provides input & feedback on clinical decision making and best practice to the Director of CM. The CM team lead will participate on committees, councils, and work as requested by the Director of CM. The CM team leader will be assist director on establishing operational solutions to meet the goals of the department, organization, and improve the patient experience.

Essential Job Responsibilities

• Provides care management services to patients and families.
• Provides an initial psychosocial assessment of patient and family functioning, adjustment to disability, health literacy status and coping skills.
• Provides education to facilitate adjustment, problem solving, and the development/implementation of an appropriate discharge/transition plan.
• Communicate with patients and families/supports to promote participation in the development and execution of the plan of care.
• Acts as an internal case manager and functions as liaison with external case managers, providers and funding sources to maximize patient satisfaction, quality, and cost-effective outcomes.
• Coordinates highly effective level of care transitions from inpatient to community-based levels of care and services, such as: outpatient rehabilitation, home care, hospice, school, vocational rehabilitation, counseling, etc.
• Oversees the patient follow up process to insure highly durable outcomes.
• Documents patient/family status, progress and discharge status through initial evaluation, progress notes, and discharge summaries according to established time standards.
• Identify and remove barriers to the discharge/transition process by:
• Identifying complex discharge/transition needs early on to assist the patient and family/supports in acquiring resources, such as: non-covered medications, home modifications, non-funded equipment, etc.
• Ensuring access to all needed follow-up primary care and medications at discharge, which may include assistance in locating funding to reduce the likelihood of re-hospitalization.
• Educate patients and families/supports on current evidence based practices related to complex /chronic disease management across the continuum of care to reduce the frequency of re-hospitalization.
• Communicates with rehabilitation team regarding patient and family needs, preferences, resources, funding issues and discharge/transition status to integrate the care process and minimize fragmentation in the services.
• Attends and participates actively in patient team conferences by representing the needs, preferences and resources of the patient and family/supports. Identify the need for and facilitate family conferences as appropriate to assure the needs and preferences of the patient and family/supports are in unison with the goals and clinical interventions of the rehabilitation team.
• Functions as a patient advocate and maintains patient confidentiality. Educate the patient, the family/supports, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions can be made.
• Promote patient self-advocacy, choice and self-determination. Educate patients and families/supports in the appropriate use of health care services. Improve quality of care and maintain cost effectiveness on a case-by-case basis.
• Provides discipline specific coverage within the Mary Free Bed System as requested.
• Participates in hiring new candidates for CM positions. Participates in orientation, competency assessment, and mentoring of new staff. Assures that appropriate clinical standards of care are met for patients in areas of assigned responsibility. Through audit activity, peer supervision, rounding, and assures standards of work are defined, followed, and adhered to by all CM staff.
• Supervises Care Managers as appropriate. Participates in performance
• Evaluations of Care Manager staff assigned and performs rounding monthly on all staff. Facilitates and encourages on-going communication between staff and leadership.
• Supports program operations as assigned.
• Provides input to strategic plans, operations of the department, strategies to improve financial aspects of department budget.
• Accreditation and Regulatory Responsibilities - The CM assists with implementing policies, procedures, and processes that align with Joint Commission, CARF, CMS, and other state hospital standards. The Clinical Care Coordinator will serve as a resource for staff in these areas.
• Leadership Must-Haves will be followed for patient and staff interactions:
  • We'll embrace all people by:

• Treating everyone with dignity and respect.
• Opening more doors to opportunity for others to succeed.
• Growing talent and people.
• Ensuring a welcoming experience for all we serve, regardless of origin, race, religion, disability, sexual orientation or socioeconomic status.
• Taking action against discrimination.
• Honoring our differences and how we collaborate.
• Educating staff, patients and the communities we care for.
• Restoring hope and freedom, together.
  • Rounding
  • Thank You Notes
  • Employee Selection/Peer Interviewing
  • Key Words at Key Times
  • AIDET + Promise
  • Standards of Behavior

Customer Service Responsibilities

Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members. This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information.

Responsibilities in Quality Improvement

Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service.

Essential Job Qualifications

• Processes and demonstrates competence in an identified area of clinical expertise.
• Registered Nurse, Masters in Social Work or Masters in Counseling from accredited school, Masters in Psychology.
• Current professional license with the State of Michigan in practice is required
• Three years of experience as a care manager in a health care setting.
• Experience working in acute rehabilitation preferred.
• Excellent verbal and written communication skills, expressing self in a clear, concise, and professional manner.
• Ability to work collaboratively and effectively with the interdisciplinary team members and family.
• Excellent time management and organizational skills. Function in a self-directed manner. Ability to make quality, collaborative decisions in short timeframes.
• Analytical and strong problem-solving skills. Ability to work effectively and efficiently under tight deadlines, high volumes and multiple interruptions.

Preferred Job Qualifications

• Experience in interdisciplinary team management.

Physical Requirements for Essential Job Qualification

None

Occasionally

(Less than 1/3)

Frequently (1/3 to 2/3)

Majority (More than 2/3)

• Remain in a stationary position: Majority
• Traverse or move around work location: None
• Use keyboard: Frequently
• Operate or use department specific equipment: None
• Ascend/Descend equipment or ladder: None
• Position self to accomplish the Essential Functions of the role: None
• Receive and communicate information and ideas for understanding: Frequently

Transport, position, and/or exert force

• Up to 10 pounds: Occasionally

Consistent with the Americans with Disabilities Act (ADA), it is the policy of Mary Free Bed Rehabilitation Hospital to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Talent Acquisition team at recruitment@maryfreebed.com.

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.