Employment Type:Full timeShift:Day ShiftDescription:The Complex Care Manager can be a RN or MSW with experience. This role will be responsible for all aspects of the depending on their licensure, including, but not limited to, the following: coordinating continuum of care activities for identified patients and ensuring optimum utilization of resources, service delivery, and compliance with external review agencies’ requirements.
Partner with the assigned Acute Care Manager (ACM) or Social Worker (SW) when teamwork and the sharing of tasks will facilitate negotiation of services and development of discharge plans.
Assume primary Care Management responsibility for a limited number of patients whose needs cannot be managed by or are beyond the scope of practice of the assigned ACM or SW.
Document new resources and post on Care Coordination Sharepoint in an organized format for use by the Care Coordination Team.
Develop financial agreements with dialysis centers, agencies, or facilities for provision of services not covered by insurance. Act as the go-between hospital leadership and these facilities for all financial agreements.
Actively involve outside entities (e.g. Consulates, MFP, DHHS, mental health entities, etc…) when special partnerships are required to address unique needs of a patient.
Follow patients in the community as needed after hospital discharge to secure resources and benefits necessary to prevent readmission and promote successful transitions.
Maintain a partnership with contracted eligibility unit as we actively pursue anticipated benefits.
Provide a weekly report on the active cases to hospital leadership.
Participate in meetings with community collaborators to build working relationships and create resources that support the Holy Cross Health mission.
Attend LOS meetings for the purpose of consultation regarding planning for care transitions.
Manage Guardianship Consults including obtaining the affidavit of capacity, meeting with potential guardians to review the application process and assisting with paperwork as necessary, collaborating with DSS, and filing court documents when needed. Provide a weekly guardianship report to hospital leadership.
Provide education to staff members on the role of CCC and Guardianship.
Manage the transition logistics for these patients out of the hospital.
Other duties as assigned
Our Commitment to Diversity and InclusionTrinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.Our Commitment to Diversity and InclusionTrinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.EOE including disability/veteran