13,892 Care Planning jobs in the United States

Lowell General Hospital has delivered high-quality and compassionate care since 1891. Our two inpatient hospital campuses, Cancer Center, Heart and Vascular Center, four urgent care locations, affiliated physicians and outpatient facilities provide state-of-the-art technology and a full range of specialty services in the Merrimack Valley.

Job Overview

Reporting to the Vice President of Patient Care Services and Chief Nurse Executive, this position has oversight of all clinical and administrative functions of the case management and social work departments in a four-time designated ANCC Magnet designated organization, and supports a dynamic staff of approximately 50 individuals.  This candidate will have strong alignment and engagement across the Tufts Medicine entities and providers in support of system and organization care management goals.  .

Job Description

Minimum Qualifications:
1. Massachusetts RN Licensure.

2. 7 Years of RN Experience with at least 5 years of management experience.

3. Current Basic Life Support (BLS) Certification.

4. Bachelor of Science in Nursing (BSN).

5. Master's Degree in Health Administration, Nursing, Business Administration, or another related field.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned.

1. Initiates and manages change, ensuring appropriate support and resources to staff.

2. Creates opportunities for multidisciplinary forums in order to solve problems and facilitate planning.

3. Monitors and ensures excellence in the clinical practice of nursing and the delivery of patient care on unit.

4. Integrates the nursing service philosophy into all unit practices and programs.

5. Keeps current with literature regarding changing practices, interventions, and research in patient care and health care delivery.

6. Utilizes a performance improvement process to assess the response to care from patients, families, and others.

7. Provides leadership in setting the direction of the unit and is responsive to changing internal and external factors.

8. Maintains open communication with managers whose departments provide support services to the clinical area in order to ensure the appropriate level of service at all times.

9. Manages human, fiscal, and other resources needed to support clinical nursing practice and positive patient outcomes.

10. Provides leadership in developing quality driven and cost-effective programs of care.

11. Monitors and critically analyzes resource utilization of the unit.

12. Collaborates with physicians, hospital administrators, and other relevant groups on methods of delivering care.

13. Provides leadership in developing quality driven and cost-effective programs of care.

14. Ensures appropriate staffing plan to accommodate changing needs of the unit.

15. Utilizes knowledge of federal, state, hospital, unit and accreditation agencies standards, policies and procedures to direct patient care.

16. Oversees operating and capital budget; implements strategies to improve efficiency and reduce costs.

17. Creates and fosters a learning environment that facilities the professional growth and development of staff.

18. Oversees written policies and procedures.

Physical Requirements: 

1. Ability to sit for extended periods of time.

2. Occasional lifting of 5-15 lbs and turning patients.

3. Occasional twisting, bending, reaching, pushing/pulling, sitting, kneeling, and squatting.

Skills & Abilities:

1. Ability to effectively communicate with patients, families, physicians, and healthcare team.

2. Ability to maintain and develop clinical knowledge, judgment, and skills.

3. Knowledge of and application of the nursing process.

4. Possesses strong clinical and theoretical skills.

5. Demonstrates proactive approach.

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Nursing Leadership duties: Controls, directs, and participates in the activities of the organization through a hierarchy of managers and supervisors. Responsibilities also include long-term strategic planning, determining the policies of the organization, and allocating its resources and making decisions regarding organization growth and diversification to accomplish entity's vision. A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and/or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and/or indirect reports. A role that manages experienced professionals who exercise latitude and independence in assignments. Responsibilities typically include: policy and strategy implementation for short-term results (1 year or less), problems faced are difficult to moderately complex, and influences others outside of own job area regarding policies, practices and procedures.

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

• Communicates in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner; listens and responds to the ideas of others.

• Collaborates with staff from the interprofessional health care team concerning safety data to improve outcomes and the safe transition of care. Uses a structured format for regular communication with patients and families.

• Contributes towards improvement of department scores for employee engagement, i.e. peer-to-peer accountability.

• Assesses all patients timely and thoroughly. Participates in daily Care Coordination Rounds (CCR), and identifies, communicates barriers to efficient patient throughput. Supports patients and families in preventing/resolving clinical or ethical issues.

• Facilitates discharge planning activities for assigned patients and collaborates with the social worker and other members of the interprofessional health care team, as well as patient and family, on complex discharges. Maintains ownership of the discharge planning process on assigned units.

• Initiates and facilitates referrals for home health care, hospice, and durable medical equipment. Consults with Social Worker Case Manager to assess psychosocial needs associated with transition to alternative levels of care, ensuring discharge disposition is to the appropriate level. Facilitates transfers.

• Modifies care based on continuous evaluation of the patient's condition, demonstrates clinical problem-solving and critical thinking, and makes decisions using evidence-based analytical approach. Documents accurate assessment and interventions efficiently and effectively.

• Plans for routine discharge and elevates emergent situations. Manages usual patient assignment and other unit demands and anticipates/plans for potential problems.

• Focuses on discharge domain by contributing to department and hospital targets for quality, patient satisfaction and safety measures.

• Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance using nationally recognized screening guidelines. Manages assigned patients in Observation Status, daily, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital.

• Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay.

• Participates in denial mitigation activities to ensure appropriate reimbursement for services rendered.

• Contributes to meeting department and hospital financial target, with focus on length of stay. Utilizes resources with cost effectiveness and value creation in mind. Self-motivated to independently manage time effectively and prioritize daily tasks, assisting coworkers as needed.

• Identifies areas for improvement based on understanding of evidence-based practice literature. Initiates evidence-based practice/performance improvement projects based on these observations and offers solutions by participating in unit projects and activities.

• Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an on-going basis.

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.

• Bachelor's degree preferred

• Three years hospital nursing clinical experience

• Case management experience preferred

• RN - Registered Nurse - Texas State Licensure - Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency)

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Knowledge of Medicare, Medicaid and Managed Care requirements

• Progressive knowledge of community resources, health care financial and payor requirements/issues, and eligibility for state, local and federal programs

• Progressive knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement

• Understanding of pre-acute and post-acute venues of care and post-acute community resources

• Ability to work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families

• Well versed in computer skills of the entire Microsoft Office Suite (Excel, Outlook, PowerPoint and Word)

• Strong assessment, organizational and problem-solving skill

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

• On Call* Yes

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

• Responsible for oversight of the Case Management and Social Work Departments in Acute Care facilities.
• Direct the operations of the Case Management and Social Work Departments from a system approach, while leading and coordinating key strategic and functional services to support departmental, facility, and organizational goals.
• Establishes system performance expectations for the department and provides direction, feedback, and guidance to employees.
• Ensures that department/functional operations across the system are in full compliance with accrediting and regulatory agency standards.
• Develops and implements system departmental policies and procedures across all case management and social work departments.
• Routinely audits and tracks for quality assurance, analyzes data to identify opportunities and acts upon data.
• Analyzes patient data and case management outcomes from a system approach to identify trends, inefficiencies, and areas for improvement in transition of care/discharge planning and utilization review.
• Holds staff accountable to follow care management processes to support quality and compliance.
• Supports national standards for case management scope of service: Education, Care Coordination, Compliance, Transition Management and Resource Utilization.
• Collaborates with case management managers and others across the system to achieve standardized practices and processes related to case management including readmission prevention, use of predictive readmission tool and application of appropriate interventions, length-of-stay management, denial prevention related to medical necessity through proactively addressing barriers to care transitions (including tracking of avoidable days/delays), daily team rounding, and patient satisfaction related to care transitions.
• Works closely with community health, ambulatory and population health partners in efforts to support patients across the care continuum.
• Collaborates with external and internal ambulatory and post-acute providers/staff to ensure seamless transitions of care.
• Works closely with post-acute network partners on key initiatives and efforts to reduce unnecessary post-acute care utilization, when safe and appropriate.
• Participate in development and management of a system post-acute provider network.
• Leads a regular cadence of meetings with post-acute partners to analyze data and trends, discuss concerns, and increase collaboration.
• Coordinates and monitors the development of long-range plans and annual budgets for Case Management and Social work departments in the acute care facilities.
• Leads the implementation and oversight of the Utilization Management Plan using data to drive hospital utilization performance improvement.
• Leads system Utilization Management Committee.
• Partners with facility and system physician leaders to optimize the Utilization Management Committee, providing actionable data related to utilization opportunities identified through qualitative data, and quantitative data
• Manage department operations to ensure effective throughput and reimbursement for services provided.
• Ensure medical necessity and revenue cycle processes are completed accurately and in compliance with governmental regulations and organizational policy.
• Coordinates education opportunities for case management personnel & physicians regarding continuum of care, reimbursement, regulations, and care issues.
• In collaboration EVP, Chief Physician Executive, provides oversight to the physician advisor program.
• Monitor and evaluate effectiveness of physician advisor program on a system level including status determination, peer to peer outcomes, and productivity.
• Provides support to system Clinical Documentation Improvement program through oversight of physician advisor program.
• Demonstrates ability to make decisions, balancing needs of the patient, within confines of various internal and external factors
• Demonstrates knowledge of federal state Medicare/Medicaid and other regulations affecting reimbursement utilization and discharge planning
• Demonstrates knowledge of insurance/government/contracts reimbursement methodologies
• Demonstrates knowledge of InterQual and multiple criteria sets and able to apply to patient populations.
• Develops and implements strategies to improve workflows and processes/procedures to enhance the utilization review program.

• Performs other duties as assigned.

• Five years of progressively responsible leadership experience in healthcare.
• Five years of Case Management and Utilization Review experience.
• Bachelor's degree in nursing from an accredited institution.
• License to practice as a registered nurse in the Commonwealth of Virginia.
• Case Management certification within 1 year of hire.
  
  Preferred Qualifications:
• Master's degree in nursing or related field.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

For West Virginia Locations:
1. Master's Degree in Social Work or related field.
2. Licensed Graduate Social Worker (LGSW), Licensed Certified Social Worker (LCSW), or Licensed Independent Clinical Social Worker (LICSW) through West Virginia Board of Social Work.
For Ohio Locations:
1. Master's Degree in Social Work or related field.
2. Licensed Social Worker (LSW), Licensed Independent Social Worker (LISW), or Licensed Independent Social Worker-Supervision (LISW-S) through Ohio Counselor, Social Worker, and Marriage and Family Therapist Board.
For Maryland Locations:
1. Master's Degree in Social Work or related field.
2. Licensed Graduate Social Worker (LGSW), Licensed Certified Social Worker (LCSW), or Licensed Certified Social Worker-Clinical (LISW-C) through Maryland Board of Social Work Examiners.
For Pennsylvania Locations:
1. Master's Degree in Social Work or related field.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certification in Case Management.

For Pennsylvania Locations:
2. Licensed Social Worker or Licensed Clinical Social Worker through Pennsylvania Department of State.
EXPERIENCE:
1. Two (2) years' social work experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Provide psychosocial assessments of patients and families to identify emotional, social, and community strengths and problems related to their diagnosis, illness, treatment, and/or life situation.
2. Participates as an integral professional in a member of an interdisciplinary treatment team led by physician.
3. Formulate, develop, and implement comprehensive treatment plans utilizing appropriate and evidence based treatments and interventions. Interventions may include crisis intervention, solution focused brief intervention, and any other.
4. Screens, educate on diagnosis, and provide therapy and interventions to individuals with a variety of presenting problems including substance abuse, depression, and anxiety, thought disorders, trauma, and autism spectrum. May perform these functions independently or as part of a team. (if under the supervision of LICSW)
5. Provide consultative services to health care team members within scope of care definitions as needed. Maintain a working knowledge of relevant medical/legal issues that impact on patient care, e.g., advance directives, child and elder abuse.
6. Provide education to patients and families around issues related to adaptation to the patient's diagnosis, illness, treatment and/or life situation.
7. Participate in multi-disciplinary health care teams and represent clinical social work perspective/liaison with patient and family.
8. May formulate, develop, and implement discharge plan beginning on the day of admission through length of stay.
9. Acts as a liaison with community agencies and resources to assist patients and families as needed.
10. May facilitate cognitive/psychoeducational group therapy at a minimum of once per day and provide individual Solution Focused Brief therapy and crisis intervention as ordered by doctor and/or as needed.
11. Provide updates and information to families / support persons and care providers through length of patient stay and facilitate family meetings to provide discharge planning and education to family, as applicable.
12. Facilitate referrals to placement options including but not limited to; personal care home, nursing home, skilled rehab, assisted living, group homes.
13. Document assessment, plan, interactions, and interventions according to departmental, hospital and/or health system guidelines and standards.
14. Maintain electronic medical records and documentation in accordance with department, hospital, medical center and/or health system policies. Attend and participate in staff, committee, department, and other administrative meetings.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Prolonged periods of standing or sitting.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Flexible hours to include weekends and holidays for inpatient setting.

SKILLS AND ABILITIES:

1. Excellent verbal and written communication skills.
2. Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes.
3. Basic computer knowledge and ability to operate standard office software.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Address:

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

Provides care management through a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet member's health needs through communication and available resources, while promoting quality cost-effective outcomes. Maintains members in the most independent living situation possible; ensures consistent care along entire health care continuum by assessing and closely monitoring members' needs and status. Provides care management services and authorizes/ coordinates services within a capitated managed care system. Communicates and collaborates with primary care practitioners, interdisciplinary team and family members.

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Assesses, plans and provides intensive and continuous care management across acute, home, and long-term care settings. Develops and negotiates care plans with members, families and physicians.
• Assesses a person's living condition/situation, cultural influences, and functioning to identify the individual's needs; develops a comprehensive care plan that addresses those needs.
• Assesses an enrollee's eligibility for Program services based on his or her health, medical, financial, legal and psychosocial status, initially and on an ongoing basis.
• Plans specific objectives, goals and actions designed to meet the member's needs as identified in the assessment process that are action-oriented, time-specific and cost effective.
• Implements specific care management activities and or interventions that lead to accomplishing the goals set forth in the plan of care.
• Coordinates, facilitates and arranges for long term care services in the home and community-based sites, such as adult day care, nursing homes, rehab facilities, etc. Arranges for on-going nursing care, service authorization and periodic assessment.
• Collaborates and negotiates with interdisciplinary teams, health care providers, family members, and third party payors, as applicable, across all health settings to ensure optimum delivery and coordination of services to members.
• Monitors care management activities, services, and members' responses to interventions, to determine the effectiveness of the plan of care and the utilization of services.
• Evaluates the effectiveness of the plan of care in reaching desired outcomes and goals; makes modifications or changes in the plan of care as needed.
• Identifies trends and needs of groups in the community and plans interventions based on these identified needs.
• Provides care management services across sites and collaborates with appropriate facility discharge planner and/or HCC when members are transitioned between settings.
• Manages expenditures to ensure effective use of covered services within a capitated rate. Fiscally responsible in providing services based on members' needs.
• Provides social work services in accordance with NASW code of ethics, VNS Health policies, practices, and procedures.
• Participates in outreach activities to promote knowledge of the Program and its services and to coordinate Program activities with outside community agencies and health care providers (e.g., community health screening, In Services).
• Participates in the development of programs to meet the specialized needs of this selected patient population.
• Documents services in accordance with Health Plans Community Care standards and Managed Long Term Care (MLTC) and Licensed Home Care Services Agency (LHCSA) regulations.
• For Palliative Care Only:
• Understands and supports ability to cope with patients' illness. Provides emotional, spiritual, and practical support for patient and family
• Reviews tools, programs and other resources for potential serious illness program appropriate patients and make referral as necessary.
• Provides education to patients and their families to better understand patients' disease and diagnosis.
• Facilitates open discussion about treatment choices for patient's illness (including difficult and complex choices) and management of symptoms.
• Provides expertise in treatment of pain and other symptoms.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:
License and current registration to practice as a Licensed Social Worker in New York State preferred

Education:
Master's Degree in Social Work required Case Management Certification preferred

Work Experience:
Minimum of three years of Social Work experience required Minimum of two years in a case management and/or community based environment preferred Bilingual skills may be required, as determined by operational needs. Clinical expertise in geriatrics, Long Term care and Managed care experience preferred