On-Site Case Manager, Vancouver WA

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• On-site Case Manager for Peacehealth Southwest Medical Center
  
  Responsibilities for Case Managers include:
  -Making outbound calls to assess members' current health status
  -Identifying gaps or barriers in treatment plans
  -Providing patient education to assist with self management
  -Interacting with Medical Directors on challenging cases
  -Coordinating care for members
  -Making referrals to outside sources
  -Coordinating services as needed (home health, DME, etc.)
  -Educating members on disease processes
  -Encouraging members to make healthy lifestyle changes
  -Documenting and tracking findings
  -Utilizing Milliman criteria to determine if patients are in the correct hospital setting
  -Making welcome home calls to ensure that discharged member receive the necessary services and resources
  
  
  Field-based Case Managers will lead the new frontier in care coordination in the emerging provider market through full partnerships with health systems, hospitals, physicians, communities, patients and their families.
  
  
  
  In this role, the Field-based Case Manager will interact and collaborate daily with hospital licensed caregivers, health system physicians, internal and external vendors, patients and families. The Field-based Case Manager will be integral to the identification of population health management opportunities as well as the strategic development and design of these services.
  
  Value is demonstrated through a reduction in the hospital readmission rates of select patients and improved adherence to evidence based medicine guidelines and industry quality standards. The Field-based Case Manager implements wide reaching change by contributing to the transformation of a health care system that meets the demand for safe, quality, patient centered and affordable care.
  
  Responsibilities:
  
  - Manage targeted population daily census
  
  - Identifying those patients appropriate for face to face contact
  
  - Meeting with patients and caregivers/families while inpatient to establish relationship and engage in transitional case management process
  
  - Assess adequacy of discharge plan and risk associated with compliance
  
  - Complete assessments, address any identified barriers to compliance across the continuum
  
  - Develop care plan and interventions with patient and family input
  
  - Proactive post discharge follow-up; telephonically or in home as appropriate
  
  - Coordination of post discharge care with primary care physician
  
  - Interact in a collegial and collaborative fashion with hospital clinical staff to include: RNs, Social Workers, UR/UM, physicians, and nonclinical support staff
  
  - Communicate regularly with patients and families, with hospital team, and document regularly in required systems for outcome reporting
  
  - Promote cost effective health care with aligned health system networks
  
  
  
  

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.