Case Manager - Care Management

You are the voice, the coordinator and the empathetic advocate of patients facing difficult situations. Your compassion for patients and families with acute and chronic health conditions knows no limits. You are committed to working with healthcare teams to ensure every patient receives the care, comfort and dignity they deserve. If this is how you define your role as a Case Manager, we invite you to consider this opportunity.

Legacy Silverton Medical Center serves the heart of the Willamette Valley with a wide mix of services, many not typically available in a community hospital: CT scan (computerized tomography), nuclear medicine, echocardiography, family birth center and much more.

Coordinates and facilitates interdisciplinary provision of comprehensive, patient-centered, quality health care throughout the continuum for patients with acute and chronic health conditions.

Fosters achievement of optimal health care outcomes within accepted standards of care.

Serves as an expert resource to the healthcare team regarding the continuum of care, efficient use of resources, Best Practice protocols, team-based care, quality indicators and improvements, and regulatory requirements.

Ensures a smooth transition of care between multiple health care environments with planned handoffs.

Partners with patients and families in identifying health care issues and barriers to self-care in order to set priorities and engage in appropriate interventions.

Demonstrates cultural agility and employs health literacy guidelines to provide education regarding self-management strategies.

Utilizes rapid quality improvement cycles to continuously monitor, evaluate, measure, and report progress of interventions and outcomes.

Paces the case to assure appropriate and fiscally sound care coordination across the continuum.

• Facilitates daily multidisciplinary care coordination meetings to clarify patient plan of care.
• Communicates with patients and their families concerning the progress of patient recovery goals and ongoing care needs.
• Organizes and/or participates in patient care conferences.
• Coordinates care and expected outcomes between patients/families and healthcare team including nurses, social workers, physicians, therapists, and community agencies and resources.
• Develops and maintains a collaborative working relationship with all team members.
• Follows evidence-based best practice.
• Serves as the clinical resource manager for patients with complex care needs.
• Provides consultations for patients who do not follow or have multiple variances from a pre-established clinical path.
• Assesses patient care priorities with patient and staff as part of the health care team and participates in determining outcomes of interventions.
• Collaborates with patient, family, and other health care professionals in the establishment of goals and implementation of patient plan of care. May provide home visits when necessary.
• Facilitates referrals, multidisciplinary review and planning for specific patients.
• Maintains currency in case management practice and principles specific to venue.
• Ensures transition plan reflects national guidelines and/or approved protocols/pathways.
• Maintains knowledge of professional standards of practice through participation in continuing education, community and professional activities, and committee membership.
• Assists patient care team to identify and coordinate appropriate level of care across the health care continuum.
• Focuses on promoting early intervention for complex patients and communicating a coordinated plan of care to prevent unnecessary complications and negative patient outcomes.
• Communicates with UM RN(s) and with insurance and community case managers, when appropriate, to discuss benefits and obtain authorization for alternative level of care.
• Assists health care team to incorporate the educational needs of patients and/or families concerning alterations in health and the disease process into the plan of care.
• Assists with patient and family education as appropriate and necessary.
• Collaborates with Legacy leadership to identify educational needs of staff.
• Participates in and/or leads committees and…