Hospital Case Manager

Round daily on assigned hospital patients and weekly on skilled nursing facility residents to monitor admissions and continued stays for medical appropriess. Develop discharge plans in coordination with physicians, patients, and families to promote safe transitions, while assessing medical, physical, and psycho-social needs to anticipate required services and follow-up care. Enter timely information into the EMR to document communications, referrals, and authorizations, and collaborate with the Case Management team to communicate coverage determinations and post-discharge follow-up needs. Serve as the clinical liaison with hospital and administrative staff, attend the Patient Care Committee meeting, and perform clinical high-risk home visits as assigned. Maintain current knowledge of health plan benefits and preferred provider networks.