Case Manager, Rehabilitation

Overview

Title: Case Manager (CM) |
Job Type: Full Time

Kindred Hospital Sugar Land is dedicated to prioritizing well-being so you can provide exceptional care. The Acute Rehabilitation Unit (ARU) at Kindred Hospital Sugar Land offers focused inpatient rehab for patients recovering from serious illness or injury.

• Specialized Rehab Programs:
  Tailored for individuals recovering from stroke, brain or spinal cord injury, orthopedic trauma, neurological conditions, or amputation. The goal is to restore independence and function.
• Modern Facilities: 11 private rooms, a state-of-the-art rehab gym, and spaces for dining and activities designed to feel home-like.
• Therapy Intensity:
  Patients receive at least 15 hours of therapy per week, guided by a multidisciplinary team under the direction of a physiatrist.
• Seamless Transition: ARU is located within Kindred Hospital Sugar Land, allowing direct movement from long-term acute care to rehabilitation without transferring to another facility.
• Outdoor Mobility Areas:
  Outdoor spaces for walking practice and family interaction to support physical and emotional recovery.

Coordinates management of care and ensures optimal utilization of resources, service delivery, and compliance with external review agencies. Provides ongoing support through comprehensive assessment, care planning, plan implementation, and evaluation of patient needs. Enhances quality of patient management and satisfaction to promote continuity of care and cost-effectiveness through integrating case management, utilization review, and discharge planning functions.

Provides ongoing support through comprehensive assessment, care coordination, plan implementation, and overall evaluation of patient needs while honoring patient preferences.

Serves as a patient advocate through resource utilization, discharge planning, and addressing the holistic needs of the patient.

The Case Manager (CM) is responsible for care coordination including needs assessment, identifying care options, communicating with patients and families in an interdisciplinary environment in line with qualifications, professional practices, and ethical standards.

Promotes the hospital's mission, vision, and values.

• Completes departmental orientation, initial and annual competencies.
• Assists with departmental performance improvement initiatives by collecting and reporting data as requested by supervisor.
• Consults with other departmental staff to collaborate in patient care delivery, identify barriers to care or discharge, and develop solutions.
• Completes documentation per workflow timeline and CMS guidelines, including the Individual Plan of Care (IPoC).
• Schedules family conferences and communicates with caregivers after team conferences to keep them informed of progress and discharge plans.
• Coordinates weekly patient care team conferences to develop and monitor treatment plans and outcomes.
• Reviews the patient's CMG to identify missed comorbid conditions and communicates findings to the HIM team.
• Ensures effective communication with nursing, therapy, and other departments to ensure proper utilization.
• If no Lead Case Manager is available, participates in national CM Conference calls and shares new information with facility CMs.
• Assists with concurrent and retrospective utilization review, including denials and appeals; works with physicians for peer reviews with payer medical directors when indicated.
• Ensures clinical updates are provided to insurance payers and that payer communications are documented in Meditech.
• Coordinates discharge planning including home health services, follow-up care, durable medical equipment, medical supplies, outpatient therapy, dialysis, skilled nursing, hospice, private duty care, and related services. Ensures a safe and thorough discharge plan with patient choice documented per CMS discharge planning requirements.
• Identifies trends impacting quality, cost, patient experience, and delivery of care and brings them to leadership for action.
• Performs intake assessment within 24 to 72 hours of admission (preferably within 48 hours).
• Performs follow-up assessments per Case Management Plan and hospital policy.
• Demonstrates flexibility, organization, and ability to function under stress.
• Other duties as assigned.

• Current licensure as a Registered Nurse or Social Worker, or healthcare professional licensure as Respiratory Therapist, Physical Therapist, Speech-Language Pathologist, or Occupational Therapist.
• Certification in Case Management or Rehabilitation Nursing preferred (e.g., CCM, ARN, ACM, or ANCC CM board certification such as RN-BC).
• Minimum of 2 years of social work or case management experience in an inpatient setting preferred; acute/rehabilitation hospital experience preferred.
• Effective oral and written communication skills in English; additional languages preferred.
• Basic computer skills (Excel, Word, Outlook, PowerPoint) required.
• Strong organizational,…