Care Case Manager well-versed in assessing patients with chronic medical conditions. Develops and facilitates care plan and advocates for patient to meet comprehensive health needs and promote enhanced outcomes, improved compliance and better patient self-management. Encourages optimum level of wellness and functional capability to benefit patient, health care delivery systems and various reimbursement sources.
Duties: Interim contract to fulfill social work requirements in the SNF portion of Westminster Manor while the authorized social worker was on parental leave.
Experience with complex case management. Home visits or Assisted Living and Rehabilitation facility visits .Psychosocial and crisis intervention skills, ability to identify community resources and service needs and facilitate appropriate referrals as needed, ability to identify and ensure that patients are transitioned to appropriate levels of care in a timely and effective manner, Development of Individual Care Plans based on measurable outcomes. Motivational interviewing techniques utilized with clients. Education of client and family on management of chronic medical conditions. Coordination of care and services such as medical appointments and in-home care. Training of in-home caregivers. Long-term caseload averaged twenty-five clients. Transitional or short-term clients numbered four hundred. Primary focus of the program to identify complex case management clients and reduce return to hospital. Use of proprietary Humana EHR software for client documentation.