Care Manager - Vandalia

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Care Manager - Vandalia Mary Free Bed Summary We have the great privilege of helping patients and families re-build their lives. It's extraordinarily meaningful work and the reason we greet the day with optimism and anticipation. When patients "Ask for Mary," they experience a culture that has been sculpted for more than a century. Our hallmark is to carefully listen to patients and innovatively serve them. This is true of every employee, from support staff and leadership, to clinicians and care providers. Mary Free Bed is a not-for-profit, nationally accredited rehabilitation hospital serving thousands of children and adults each year through inpatient, outpatient, sub-acute rehabilitation, orthotics and prosthetics and home and community programs. With the most comprehensive rehabilitation services in Michigan and an exclusive focus on rehabilitation, Mary Free Bed physicians, nurses and therapists help our patients achieve outstanding clinical outcomes. The growing Mary Free Bed Network provides patients throughout the system with access to our unique standard of care. Mission Statement Restoring hope and freedom through rehabilitation. Employment Value Proposition At Mary Free Bed, we take pride in our values-based culture: - Focus on Patient Care. A selfless drive to serve and heal connects all MFB employees. - Clinical Variety and Challenge. An inter-disciplinary approach and a top team of professionals create ever-changing opportunities and activities. - Family Culture. We offer the stability of a large organization while nurturing the family/team atmosphere of a small organization. - Trust in Each Other. Each employee knows that co-workers can be trusted to make the right decision for our family, patients, staff, and community. - A Proud Tradition. Years of dedicated, quality service to our patients and community have yielded a reputation that fills our employees with pride. Age Specific Responsibility Must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in assigned department. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to age-specific needs and to provide the care needed as described in the department's policies and procedures. Position Summary Provides care management services to all patients and families to promote optimal functioning throughout the rehabilitation process. Maintains current with clinical practice through continuing education, research, and program development. Essential Job Responsibilities - Provide patient care, treatment, and services within the scope of their license, certification or registration and as required by Federal and State laws and regulations. - Provides care management services to patients and families. - Provides an initial psychosocial assessment of patient and family functioning, adjustment to disability, health literacy status and coping skills. - Provides education to facilitate adjustment, problem solving, and the development/implementation of an appropriate discharge/transition plan. - Communicate with patients and families/supports to promote participation in the development and execution of the plan of care. - Acts as an internal case manager and functions as liaison with external case managers, providers and funding sources to maximize patient satisfaction, quality, and cost-effective outcomes. - Coordinates highly effective level of care transitions from inpatient to community-based levels of care and services, such as: outpatient rehabilitation, home care, hospice, school, vocational rehabilitation, counseling, etc. - Oversees the patient follow up process to insure highly durable outcomes. - Documents patient/family status, progress and discharge status through initial evaluation, progress notes, and discharge summaries according to established time standards. - Identify and remove barriers to the discharge/transition process by: Identifying complex discharge/transition needs early on to assist the patient and family/supports in acquiring resources, such as: non-covered medications, home modifications, non-funded equipment, etc. Ensuring access to all needed follow-up primary care and medications at discharge, which may include assistance in locating funding to reduce the likelihood of re-hospitalization. Educate patients and families/supports on current evidence-based practices related to complex /chronic disease management across the continuum of care to reduce the frequency of re-hospitalization. Communicates with rehabilitation team regarding patient and family needs, preferences, resources, funding issues and discharge/transition status to integrate the care process and minimize fragmentation in the services. - Attends and leads in-patient team conferenc

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