Piedmont Healthcare
Description:JOB PURPOSE:Coordinates and monitors all Care Management team activities, provides leadership, coaching, andmentoring to Care Management staff members. Responsible for providing leadership and direction forDischarge Planning and Transitions of Care, within the acute hospital. Monitors for quality indicators toassure appropriate social and transitional services are provided to patients and families. Develops andmaintains relationships with physicians, nursing supervisors, payers, community resources/ agencies toprovide the needs services for indigent, uninsured, and underinsured populations.Qualifications:MINIMUM EDUCATION REQUIRED:Associate s Degree from accredited school of Nursing or Masters in Social Work and current Social Worklicensure in the State of Georgia.MINIMUM EXPERIENCE REQUIRED:Two (2) years of experience in care management, medical social work or transitional care management.MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:Registered Nurse (RN) or Licensed Master Social Worker (LMSW) and current license in state of GAADDITIONAL QUALIFICATIONS:KEY RESPONSIBILITIES:1. Provides onsite mentoring, orientation and supervision for Care Management staff to ensure alignmentwith department metrics.2. Communicates with charge nurses, physicians, ED staff and leadership regarding complex dischargeplanning, transitional care, complex psycho/social, psychiatric cases, or high-risk patients that are atrisk for readmissions.3. Provides mediation between the patient, provider, guardians, family members or agencies relative tothe needs and desires identified by the patient.4. Orient new staff and assist in identifying process improvement opportunities5. Coordinate various aspects of Care Management services; including referral, intake, eligibilitydetermination, program planning, monitoring, assessment, and evaluation of needs and services.6. Collaborate with post-acute care providers to secure safe and timely discharges.7. Prepare weekend schedule, monitor PRN staff to ensure compliance w/meeting work requirements.8. Provide guidance and leadership on complex/acute inpatient and ED patients; assist with educatingED Staff and collaborate with UR on out of network patients and appropriate diversions.9. Track weekend discharges; discharge delays; escalations, family meetings, etc.10. Huddle with Charge RNs and MDs to address discharge needs.11. Huddle with House Supervisor to discuss bed needs.12. Monitor/Audit regulatory compliance of IMM/Moon notices on the weekend.13. Facilitate weekend huddle to address discharge barriers, Kepro/Medicare appeals and any otherescalations.