Care Manager/Full time/Wallingford

Gaylord Specialty Healthcare is a health system dedicated exclusively to medical rehabilitation. We provide inpatient and outpatient care for people at every point in their journey from illness or injury to the most advanced state of recovery they can achieve. Our Mission: To enhance health, maximize function, and transform lives. Our values: Integrity, Compassion, Accountability, Respect and Excellence. These values guide us in providing quality patient care and transforming the lives of our patients. SUMMARY: Coordinates all health care services required for an organized, multi-disciplinary team approach to management of designated patient populations. Initiates discharge planning in a timely fashion, develops and revises individualized discharge plans as indicated by assessment and patient response to treatment. Assesses quality, cost-efficient care to ensure the patient’s plan of care promotes a safe and timely discharge. Evaluates the overall plan for effectiveness. Involves the patient and family in the formulation of goals. Monitors appropriateness of admissions and continued stay. Provides the link between provider and payer organizations, physicians, and the community in the transition of patient care through the health care system. ESSENTIAL DUTIES AND RESPONSIBILITIES (Performance Appraisal Competencies) – Include the following. Other duties may be assigned. CLINICAL : CRITERIA: Performs initial Care Management assessment and ongoing comprehensive reassessments of the patient’s condition and discharge planning needs including the psychosocial, physical, educational, cultural aspects, and social determinants of health. Modifies the plan, in conjunction with the clinical team, the patient, and family to meet the needs of the patient. Initiates discharge planning in a timely fashion. Developing and revising individualized discharge plans based on patient assessment and response to treatment. Ongoing evaluation of planning for effectiveness involving the patient and family in goal-setting. Demonstrates an understanding of level of care criteria and reimbursement factors for home care, rehabilitation, residential treatment, and long term care in the development of discharge plans. Pivots the plan to explore alternatives as necessary. Composes, compiles, and forwards patients’ clinical data to payers to secure continued stay and skilled nursing facility authorizations. QUALITY AND SAFETY AND UTILIZATION REVIEW: CRITERIA: Meets monthly goals for length of stay management. Maintains compliance with The Important Message from Medicare, transfer notes, post-discharge phone calls, and other functions subject to audit. Provides clinical information to managed care companies in a timely manner to prevent denials through pro-active intervention with managed care reviewers, physicians, and hospital staff. Administers Medicare notices of non-coverage to Medicare patients who do not meet medical necessity. Assures and facilitates the appropriate and efficient utilization of hospital services. Uses nationally recognized criteria in determining whether a patient meets medical necessity for LTACH level of care and takes appropriate action when variances are identified. Facilitates peer-to-peer and other appeal levels with payers to overturn denials; and documents outcomes in the denial database. Completes conservatorship paperwork, files with probate, and attends hearings as necessary. COMMUNICATION: CRITERIA: Collaborates with other disciplines in patient evaluation and treatment and initiates referrals appropriately. Forwards requests for PASRR completion to the appropriate party. Acts as the main conduit in discussing issues with patients, families, and external case managers regarding insurance benefits/reimbursement, treatment plan, progress, length of stay, and the discharge plan. Provides patients and families support and information about their current disability. Provides education and support to hospital staff regarding community resources, managed care issues, or payment/payer issues. PROFESSIONALISM AND EXPERTISE: CRITERIA: Possesses critical thinking skills for evidence-based decision making. Advocates for patients’ needs, rights, and autonomy. Ability to assess complex situations and develop effective care strategies. Pursues ongoing education and training to stay current in their role. IT IS ICARE CRITERIA: Innovation : Embracing creativity and new ideas to improve processes and outcomes. Teamwork : Collaborating effectively with others to achieve shared goals and objectives. Inclusion : Fostering an environment where everyone feels valued and supported. Safety : Prioritizing the well-being and security of patients, individuals and communities. Integrity : Acting with honesty and transparency in all interactions and decisions. Compassion : Showing empathy and kindness towards others, especially in challenging situations. Accountability : Taking responsibility for actions and outcomes, ensuring reliability and trust. Respect : Treating others with dignity and consideration, valuing their perspectives and contributions. Excellence : Striving for the highest quality in performance and achievements. QUALIFICATIONS: Registered Nurse licensed in the state of Connecticut, Bachelor’s degree preferred or in lieu of a Bachelor’s degree, a minimum of two years acute care experience. Acute care case management, home care and/or long term care experience preferred. Certification in Care Management a strong plus. Strong leadership, interpersonal, strong problem solving, goal setting, and decision making skills. Experience with multi-aged and multicultural populations. Ability to work autonomously and managed time effectively and to work within a multidisciplinary team structure. Knowledge of legal and regulatory issues, insurance, and third-party reimbursement. Experience with medical cost containment and resource utilization. Strong computer skills. HOURS: Full time We Are An Equal Opportunity Employer