Summary Christus Homecare SPOHN, a Division of LHC Group, is hiring for a Transitional Case Manager.
The Transitional Case Manager (TCM) primary responsibility is to facilitate a seamless transition for patients discharging from a facility setting to the care of an LHC Group agency for post-acute care needs. The TCM will verify home health orders, assess the care required, and ensure continuity of care and the agency's ability to meet the needs of the patient. This clinical liaison position will assess each patient to determine their level of health literacy and ensure that patients and families are included in care planning. Following identification of needs the TCM will begin best practice intervention and education to improve patient outcomes and promote patient self-management. The TCM will implement rehospitalization reduction initiatives for patients with Acute Care Hospitalization risk and continually communicate between healthcare providers during all phases of transition from the facility into the home.
Responsibilities Identifies primary care physician to follow the plan of care
Educates patient on importance of the post-facility discharge follow-up appointment with the physician
Assesses patient’s risk for readmission using LACE tool and documents in Transition encounter; Educates patient on homebound criteria and verifies patient meets these requirements
Educates LHC Group referrals on Call First process and ensures patient and family have agency contact information
Educates patient on obtaining all necessary prescriptions prior to discharge from hospital and confirms patient’s understanding of medication, pharmacy, and delivery method
Coordinates other ancillary services for the patient (DME, Infusion) as needed
Assists the LHC Group agency in preparation of accepting care of the patient post discharge
Serves as a liaison between the LHC Group agency and all involved healthcare providers of newly referred patients as well as existing patients transferred to the hospital from the home health agency
Communicates to discharge planning any active patients that transfer from home health into a facility and coordinates resumption of care with the patient prior to discharge if applicable orders are obtained
Provides follow-up feedback to case management team regarding status of readmissions and any non-admit decisions based on information provided to them by the LHC agency
Serves on facility committees, if requested, and works with hospital focus groups to assist in systems integration and process improvements which result in improved patient outcomes and transitions of care as approved by the Director
Participates in monthly Executive Director and Account Executive meetings to assist with clinical program needs
Attends all Department calls and company-provided in-services
Observes patient confidentiality at all times
Provides education in-services to effectively communicate the features, benefits, and specialty programs of LHC Group and to educate referral sources as to what services are available in the home
Demonstrates a desire to promote the LHC philosophy, "It’s All about Helping People" and seeks ways to facilitate helping more patients
Communicates with growth team and continually analyzes best practices and opportunities to provide care to and reach any underserved population within our service areas
Meets personal performance goals established by manager
Documents Start of Care transition CTC encounter note within 24 hrs of patient referral/agency acceptance and update as status of patient transfer changes
Document Resumption of Care note if applicable
CMCN to be obtained within first year of employment
All other duties as assigned
Education and Experience Experience Requirements
Must have one year home health experience or one year of hospital case management experience.
License Requirements
Must have current RN or LPN or Social Work licensure in state of practice
Reliable means of transportation and must have current driver’s license and auto insurance
Skill Requirements
Must have excellent verbal and written communication skills with all members of the healthcare team
Must have excellent organizational skills and ability to complete competing priorities
Must have thorough understanding of home health qualifying criteria and coverage guidelines
Proficient computer skills.
Company Overview LHC Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
At LHC Group we are proud to offer benefits that support your physical and emotional wellbeing. Review LHC Group’s comprehensive benefits and perks: https://bit.ly/LHCGBenefits
CHRISTUS Homecare SPOHN a part of LHC Group family of providers – the preferred post-acute care partner for hospitals, physicians, and families nationwide. We deliver high-quality, cost-effective care that supports our patients when and where they need it. From our home health, hospice, and community-based services to inpatient care at our clinics and hospitals, our mission is to reach more patients and families with effective and efficient healthcare. More hospitals, physicians, and families choose LHC Group because we are united by a single shared purpose: It's all about helping people.